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Volume 85 - 2022 - Fasc.3 - Case reports

Necrotizing soft tissue infection of the upper leg as first presentation of necrotizing pancreatitis: a case report

Acute pancreatitis can be complicated with necrosis of the pancreatic or peripancreatic tissue. This necrosis can become liquified and form a well-defined wall (walled-off necrosis or WON) and can become infected and form abscesses. Necrotizing soft tissue infections are rare infections of the deep tissue and subcutaneous fat and are mostly caused by trauma or perforated visceral organs. They can, however, rarely be caused by infected retroperitoneal collections. To date only 3 case reports have been published of a necrotizing soft tissue infection complicating a necrotizing pancreatitis. Both acute, complicated pancreatitis and necrotizing soft tissue infections carry a high mortality and morbidity rate with surgery being the mainstay therapy for the latter, often leaving the patient disfigured. We report the case of a 62-year-old man presenting to the emergency department with a painful and erythematous rash of the upper leg as complication of an acute necrotizing pancreatitis.


Parvovirus B19-triggered hemophagocytic lymphohistiocytosis in a patient with Crohn’s disease

Background: Hemophagocytic lymphohistiocytosis (HLH) is a life threatening condition caused by inappropriate immune activity. Infection is often the trigger, both in genetically predisposed and in sporadic cases. Although more commonly seen in the paediatric population, patients of all ages can be affected. Case presentation: A 26-year-old male patient with Crohn’s disease, treated with ustekinumab, presented with high fever, epistaxis and anorexia. Laboratory results showed pancytopenia, and a high serum levels of ferritin and LDH. Colonoscopy revealed only mild signs of disease activity. CT-scan showed splenomegaly and multiple lymphadenopathies. Bone marrow aspirate was suggestive for hemophagocytosis. PCR & serology for parvovirus B19 came back positive. Treatment with ustekinumab was temporarily put on hold and supportive care was given. Viral replication decreased and he recovered completely. Conclusion: There is a known association between HLH and Crohn’s disease. This is probably because they are more susceptible to infections with CMV, EBV and parvovirus B19, all known as triggers for HLH. The role of ustekinumab is unclear: did it play a role in the pathophysiological evolution of this primo-infection with parvovirus B19? On the other hand, did it contribute to the rather mild course of the disease, acting as a immunomodulator that works on interleukin-12, a cytokine that plays a role in HLH? Further study is warranted to answer these questions.


Cryptogenic multifocal ulcerative stenosing enteritis (CMUSE) diagnosed by retrograde motorized spiral enteroscopy

We present the case of a 59-years-old woman with a history of abdominal pain and iron-deficiency anemia. Upper and lower gastrointestinal endoscopy turned out negative and further investigation with wireless videocapsule showed an inflammatory stricture in the middle of the small bowel with retention of the videocapsule. Treatment with budesonide was initiated and allowed the spontaneous evacuation of the videocapsule. Retrograde motorized spiral enteroscopy was performed and confirmed an ulcerative stricture 60 cm proximal to the ileocaecal valve. Clinical, iconographic, endoscopic and histological results were compatible with a rare entity described as cryptogenic multifocal ulcerative stenosing enteritis (CMUSE). After the diagnosis budesonide was replaced by azathioprine 100 mg/d as an immunosuppressor. However, azathioprine induced mild pancreatitis and a second course of budesonide was started again. Clinical evolution was favorable.


Gastric distension and gastroparesis following pulmonary vein isolation for atrial fibrillation: a case report and review of the literature

We present a case of marked gastric distension and gastroparesis in a patient with atrial fibrillation who underwent a pulmonary vein isolation, a procedure commonly performed in patients suffering from atrial fibrillation in order to regain sinus rhythm. Two days following the procedure, the patient presented with marked abdominal distension, and computed tomography imaging was consistent with gastroparesis and/or delayed gastric emptying. A tentative diagnosis of pylorospasm was made. After a first attempt with a conservative approach, gastroscopy with both pyloric dilatation and intra-pyloric botox injection was performed due to persisting discomfort. The symptoms gradually resolved following this intervention. Gastroparesis and gastrointestinal distension is a rare complication following pulmonary vein isolation, and is mainly thought to result from temporary damaging the vagal nerve. Since a rising number of patients undergo an ablation of the pulmonary veins as treatment for atrial fibrillation, gastroenterologists should become aware of this probably not so rare complication.