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.
