Duodenal ulcers preceding cervical tuberculous lymphadenitis

Lymphadenitis is the most common presentation of extra pulmonary tuberculosis, whereas gastrointestinal localization, particularly duodenal involvement, is rare. We report a case of extra pulmonary tuberculosis with association between cervical lymphadenitis and duodenitis with multiple ulcers, not responsive to treatment with protonic pump inhibitors, in a human immunodeficiency virus-seronegative adult woman of Eritrean origin. Clinical patterns of duodenal TB, diagnostic difficulties and aetiopathogenesis are discussed according to the literature. In this case report it is suggested that tuberculous infection must be considered when duodenal ulcers fail to respond to proton pump inhibitors, especially when the patient comes from an endemic area.

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Rheumatologic manifestations of sarcoidosis

PURPOSE OF REVIEW

This review emphasizes the importance of the rheumatological signs and symptoms in the presentation of sarcoidosis. Often the presence of musculoskeletal findings may lead to the diagnosis of the disease and the institution of the appropriate treatment.

RECENT FINDINGS

There have been significant advances in the treatment of sarcoidosis with the use of biologic agents for recalcitrant and severe manifestations of the disease as well as some new data regarding pathogenetics and new applications of diagnostic imaging studies such as positron emission tomography scanning.

SUMMARY

Although pulmonary disease is the most frequent manifestation of sarcoidosis, musculoskeletal symptoms are not only common, but may be the initial presentation of this systemic inflammatory process and could mimic other arthritic and autoimmune disorders. This article focuses on the rheumatological aspects of sarcoidosis and includes a review of the most recent literature, which shows new data on the diagnosis, pathogenesis, and treatment of this condition.

The prevalence of hepatic granulomas in chronic hepatitis C

OBJECTIVES

Hepatic granulomas are not usual findings in chronic hepatitis C. A few studies addressing the frequency of hepatic granulomas in chronic hepatitis C reported it as less than 10%. The presence of it has been suggested to predict a favorable response to interferon treatment. Also, case reports described the development of hepatic granulomas after interferon treatment. In this study, we aimed to detect the prevalence of hepatic granulomas in chronic hepatitis C and to identify the causes other than chronic hepatitis C, if present, to search whether there is an association between the presence of granuloma and response to interferon treatment and also to see whether interferon leads to the formation of hepatic granulomas.

METHODS

Patients from 3 university clinics were included. All patients with chronic hepatitis C were determined. All patients with hepatic granulomas were screened for the other causes of hepatic granuloma with tuberculin skin test, chest X-ray and computed tomography, Venereal Disease Research Laboratory, and Brucella agglutination tests. The histologic assessment of liver biopsies was done by the same pathologist in each center.

RESULTS

A total of 725 liver biopsies of 605 patients with chronic hepatitis C were screened. In 8 patients, hepatic granulomas were detected in the initial liver biopsies. Four patients had repeat biopsies, and all had hepatic granulomas again. The prevalence of hepatic granulomas in patients with chronic hepatitis C was calculated as 1.3% (8 of 605) in reference to patient population. Presence or absence of hepatic granulomas was seemingly stable. All patients with hepatic granulomas had negative results of tuberculin skin test, Venereal Disease Research Laboratory, chest X-ray and computed tomography, and Brucella agglutination tests. All repeat biopsies were obtained after interferon (+/- ribavirin) in varying doses and duration. Four of 8 patients with hepatic granulomas were found to respond interferon therapy. No patient was found to develop hepatic granulomas after interferon therapy.

CONCLUSION

Hepatic granulomas are a rare finding in HCV infection. The presence of it does not seem to predict the response to interferon therapy. The development of hepatic granulomas during interferon therapy is not usual.

Typhoid fever as a rare cause of hepatic, splenic, and bone marrow granulomas

During the course of typhoid fever, the usual histologic finding of the liver is "nonspecific reactive hepatitis." Hepatic granuloma (HG) is a rare complication of typhoid fever. We present two cases of typhoid fever with HG and review the relevant literature. Case 1 (a 53-year-old female) was found to have both hepatic and splenic granulomas. This is the first case of typhoid fever with splenic granulomas in the English language literature. Case 2 (a 66-year-old male) developed granulomas in the bone marrow in addition to HG. It should be considered that typhoid fever may lead to granulomas in several organs.

The oxidant-antioxidant balance in mild asthmatic patients

We investigated the oxidant-antioxidant balance and the effect of inhaled corticosteroids on this balance in mild stable asthmatics. Included in the study were 30 mild asthmatic patients (11 male, 19 female, mean age (year) +/- SD: 35.1 +/- 9.7) and 26 healthy adults (7 male, 19 female, mean age (year) +/- SD: 40.8 +/- 13.3). In all study groups, the peripheral venous blood samples were taken for plasma malonyldialdehyde (MDA), a parameter of lipid peroxidation caused by the oxidants, and erythrocyte superoxide dismutase (SOD), an antioxidant enzyme. The mean plasma MDA level was lower in the asthmatic group (5.7 +/- 1.2 nmol/ml) than in the healthy group (6.3 +/- 1.7 nmol/ml); and the mean erythrocyte SOD level was higher in asthmatic group (1086.4 +/- 247.4 U/gHb) than in the healthy group (1028.0 +/- 230.0 U/gHb). However, there were no significant differences in measurements of both plasma MDA levels and erythrocyte SOD enzyme activities between the groups (respectively, p = 0.1 and p = 0.4). When asthmatic patients were divided into subgroups as "inhaled steroid user" and "no inhaled steroid user", no significant differences were observed in the measurements of either plasma MDA level or erythrocyte SOD enzyme activity between the mentioned subgroups. According to the results of our study, we can say that oxidant-antioxidant balance is not significantly affected in mild asthmatics or measurement of plasma level of MDA and erythrocyte SOD enzyme activity is not sensitive to the oxidant-antioxidant balance in mild asthmatics.

Sarcoidosis in untreated chronic hepatitis C virus infection

Chronic hepatitis C has been implicated in the pathogenesis of sarcoidosis in several cases of patients treated with interferon-alpha. On the other hand, only in a few cases previously has a possible link between sarcoidosis and untreated chronic hepatitis C virus infection been demonstrated. We report on a patient with chronic hepatitis C who developed cutaneous sarcoidosis without prior interferon-alpha treatment. We hypothesize that viral persistence seen in chronic hepatitis C virus infection might be one of the potential factors that trigger cellular immune response in granulomatous reactions as seen in sarcoidosis, in genetically predisposed patients.

Granulomatous liver disease and cholestasis

Development of hepatic granulomas, especially those located within portal tracts, is associated with injury to septal and interlobular bile ducts. Dysfunction of the bile ducts in turn leads to cholestasis,and ongoing damage by the granulomatous inflammation eventually results in ductopenia. A multitude of causes of hepatic granulomas have been described over the last few decades. Diligent and prioritized search for cause of hepatic granulomas should proceed within the environmental and epidemiologic context of a given patient. The therapeutic approaches, including amelioration of the cholestatic syndrome, are often determined by successful identification of specific etiologic factors causing the granulomas in the liver.

Cytomegalovirus Enteritis in Common Variable Immunodeficiency

A woman with previously undiagnosed common variable immunodeficiency presented with diarrhea and volume depletion. Biopsies from upper and lower endoscopy revealed atrophic gastritis, villous atrophy, and an inflammatory bowel disease-like chronic colitis, with absence of plasma cells in all sites. Cytomegalovirus inclusions were demonstrated in the colon and small bowel mucosa. Despite therapy with intravenous immunoglobulin and ganciclovir, the patient deteriorated rapidly and subsequently died. This case report highlights the potential for cytomegalovirus to cause extensive disease in patients with common variable immunodeficiency and, thus, the importance of considering it in the initial differential diagnosis so that further morbidity and mortality might be prevented.

Hepatic granulomas: a 10 year single centre experience

BACKGROUND

Epithelioid granulomas have been reported in 2-15% of unselected liver biopsies, with numerous underlying aetiologies described. However, all UK series were reported before identification of hepatitis C virus (HCV).

AIM

To evaluate the current aetiologies of hepatic granulomas and to assess the prognosis for the "idiopathic" group, in which all investigations for a recognised cause were negative or normal.

METHODS

A retrospective review of patient case notes between 1991 and 2001; all patients who had a liver biopsy at Glasgow Royal Infirmary revealing epithelioid granulomas had their case notes and liver biopsies reviewed and a standard proforma completed.

RESULTS

Over the study period, 1662 liver biopsies were performed. Hepatic granulomas were found in 63. Of those identified, 47 were female, with a mean age of 42 years (range, 17-81). Underlying aetiologies were as follows: primary biliary cirrhosis (PBC; 23.8%), sarcoidosis (11.1%), idiopathic (11.1%), drug induced (9.5%), HCV (9.5%), PBC/autoimmune hepatitis (AIH) overlap (6.3%), Hodgkin lymphoma (6.3%), AIH (4.8%), tuberculosis (4.8%), resolving biliary obstruction (3.2%), and other single miscellaneous causes (9.5%). Of the seven patients with idiopathic hepatic granulomas, one was lost to follow up, one died of stroke, and the remaining five were well with no liver related morbidity at a mean follow up of 6.2 years.

CONCLUSIONS

The aetiology of hepatic granulomas is broad ranging, with HCV an important cause in this population. Despite extensive investigations, a 10-15% of patients still had "idiopathic" hepatic granulomas. However, the prognosis for this last group appears to be excellent.

Mood Alterations in Patients Treated with Chlorambucil

The alkylating agent chlorambucil produces dose-limiting myelosuppression but can also cause rare central nervous system toxicities, including seizures, when given in high doses. Patients with lymphoma who were receiving intermittent pulsed oral doses of 10-12 mg/m2 chlorambucil per day for 5 days experienced marked mood alterations during therapy. These effects, which have not been reported previously, involved sleep alterations, anxiety and restlessness, irritability, and depression. All effects remitted immediately after the final day of the dosing regimen. Mood alterations should be added to the known list of chlorambucil-related toxicities and can occur with commonly used oral dosing schedules.

Pseudoneoplastic appearance of cytomegalovirus-associated colitis in nonimmunocompromised patients: report of 2 cases

Two cases of human cytomegalovirus (HCMV) colitis with pseudoneoplastic appearance are described. Patients presented with abdominal pain, fever, and diarrhea. Colonoscopy revealed a stenosing lesion in one patient and a broad-based, vegetant mass in the other patient, and histopathological examination of colectomy specimens revealed exuberant inflammatory masses with infiltration of mononuclear cells and ulcers with granulation tissue. Typical intranuclear HCMV inclusions were numerous. Peculiar to both patients was the lack of any apparent causes of immunodeficiency, such as human immunodeficiency virus infection or previous organ transplantation.

Endoscopic features of esophageal tuberculosis

BACKGROUND

Esophageal tuberculosis is rare. Clinical and endoscopic features are variable, diverse, nonspecific, and poorly described. These findings may be confused with those of esophageal cancer and deep fungal infection.

METHODS

Medical records from a 5-year period (January 1997 to December 2001) were searched for cases of esophageal tuberculosis. For identified cases, the clinical, radiologic, and endoscopic features were evaluated.

OBSERVATIONS

Four cases of esophageal tuberculosis were encountered during the 5-year period studied. Three of the patients presented with dysphagia and weight loss. One patient had aspiration pneumonia and another fatal hematemesis. Endoscopic features included deep and large proximal esophageal ulcers in 2 patients, tracheo-esophageal fistula in one, and nonhealing proximal esophageal ulcer in another patient.

CONCLUSION

The present case series indicates that certain endoscopic features, such as deep and large esophageal ulcers, tracheoesophageal fistula, and nonhealing ulcer, are strongly suggestive of tuberculosis-related esophageal lesions.

Chlorambucil-induced myoclonus in a cat with lymphoma

Chlorambucil is an alkylating agent commonly used in veterinary oncology for conditions including lymphoma. Chlorambucil neurotoxicity has been well recognized in human patients. Onsets of central nervous system signs, such as myoclonus, tremors, muscular twitching, agitation, and tonic-clonic seizures, have been reported in humans and laboratory animals treated with chlorambucil. This case of a cat with intestinal lymphoma represents the first veterinary patient reported to have chlorambucil-induced neurotoxicity. Neurotoxicity should be considered a potential side effect of chlorambucil therapy in veterinary patients.

Aldehydes and glutathione in exhaled breath condensate of children with asthma exacerbation

Oxidative stress is implicated in the pathogenesis of asthma, and clinical studies show an imbalance in the level of oxidants to the level of antioxidants in subjects with asthma. Aldehydes and glutathione are examples of biomarkers of oxidant-induced damage and antioxidant status in asthma, respectively. In the study, we applied analytical techniques based on liquid chromatography for the assessment of aldehydes and glutathione in the exhaled breath condensate of children with asthma and in control subjects without asthma. Twelve subjects with asthma were evaluated at exacerbation and after 5 days of therapy with prednisone. At exacerbation, malondialdehyde levels were higher in patients with asthma (30.2 +/- 2.4 nM) than in control subjects (19.4 +/- 1.9 nM, p = 0.002) and were reduced after steroid therapy (18.5 +/- 1.6 nM, p = 0.001). At exacerbation, glutathione levels were lower in subjects with asthma (5.96 +/- 0.6 nM) than in control subjects (14.1 +/- 0.8 nM, p < 0.0001) and were increased after the therapy (8.44 +/- 1.2 nM, p = 0.04). Malondialdehyde and glutathione both in subjects with asthma and control subjects were negatively correlated (r = -0.5, p = 0.001). The study shows that aldehydes and glutathione are detectable in the exhaled breath condensate of children with asthma and healthy children and that their levels are modified during asthma exacerbation and after a 5-day course of therapy with oral prednisone.

Determination of patterns of biologically relevant aldehydes in exhaled breath condensate of healthy subjects by liquid chromatography/atmospheric chemical ionization tandem mass spectrometry

A method for the simultaneous determination of several classes of aldehydes in exhaled breath condensate (EBC) was developed using liquid chromatography/atmospheric pressure chemical ionization tandem mass spectrometry (LC/APCI-MS/MS). EBC is a biological matrix obtained by a relatively new, simple and noninvasive technique and provides an indirect assessment of pulmonary status. The measurement of aldehydes in EBC represents a biomarker of the effect of oxidative stress caused by smoke, disease, or strong oxidants like ozone. Malondialdehyde (MDA), acrolein, alpha,beta-unsaturated hydroxylated aldehydes [namely 4-hydroxyhexenal (4-HHE) and 4-hydroxynonenal (4-HNE)], and saturated aldehydes (n-hexanal, n-heptanal and n-nonanal) were measured in EBC after derivatization with 2,4-dinitrophenylhydrazine (DNPH). Atmospheric pressure chemical ionization of the analytes was obtained in positive-ion mode for MDA, and in negative-ion mode for acrolein, 4-HHE, 4-HNE, and saturated aldehydes. DNPH derivatives were separated on a C18 column using variable proportions of 20 mM aqueous acetic acid and methanol. Linearity was established over 4-5 orders of magnitude and limits of detection were in the 0.3-1.0 nM range. Intra-day and inter-day precision were in the 1.3-9.9% range for all the compounds. MDA, acrolein and n-alkanals were detectable in all EBC samples, whereas the highly reactive 4-HHE and 4-HNE were found in only a few samples. Statistically significant higher concentrations of MDA, acrolein and n-hexanal were found in EBC from smokers.

Gastrointestinal metastasis to the breast

BACKGROUND

Although primary breast cancer is common, metastatic disease to the breast, especially primary gastrointestinal cancer, is rare. Routine pathologic examination may be helpful in determining the true diagnosis, but can be misleading.

METHODS

To determine whether a signet ring carcinoma was a primary malignancy of the gastrointestinal tract metastatic to the breast or vice versa, histochemical analysis was performed for Her-2/NEU, gross cystic disease fluid protein-15, estrogen receptor, progesterone, carcinoembryonic antigen, cytokeratin 7, and cytokeratin 20.

RESULTS

Positive staining for carcinoembryonic antigen and cytokeratin 20 (and negative staining for the breast cancer antigens), and the clinical criteria favors the diagnosis of gastrointestinal carcinoma metastatic to the mammary gland.

CONCLUSIONS

Because the prognosis of therapy for metastatic cancer to the breast differs from that of primary breast cancer, it is imperative that the correct diagnosis be established. Immunohistochemistry for carcinoembryonic antigen and cytokeratin 20 are particularly useful. Metastatic gastrointestinal carcinoma to the breast is a rare lesion but needs to be at least included in the differential diagnosis of breast masses, especially in patients with a history of gastrointestinal cancer.

Cholestatic syndromes

Further insights into the molecular regulation of bile acid transport and metabolism have provided the basis for a better understanding of the pathogenesis of cholestatic liver diseases. Novel insights into the mechanisms of action of ursodeoxycholic acid should advance our understanding of the treatment of cholestatic liver diseases. Mutations of transporter genes can cause hereditary cholestatic syndromes in both infants and adults as well as cholesterol gallstone disease. Important studies have been published on the pathogenesis, clinical features, and treatment of primary biliary cirrhosis, drug-induced cholestasis, and cholestasis of pregnancy.

Gastrointestinal infections in the immunocompromised host

Immunocompromised patients, including patients with AIDS, solid organ and bone marrow transplant recipients, patients with leukemia and lymphoma, patients with inherited immune deficiencies, and patients on immunosuppressive therapy for a variety of disorders, are at risk for infections-particularly opportunistic infections, which, by definition, do not infect the healthy host. All systems of the body, including the gastrointestinal tract, are susceptible. The esophagus, stomach, small intestine, and large intestine are sites of infection for viruses, bacteria, fungi, and protozoa. Symptoms can range in severity from fevers of unknown etiology to life-threatening hemorrhage and perforation. This review summarizes recent case reports, clinical studies, and reviews pertaining to pathogens that uniquely cause disease, more frequently cause disease, or cause more severe disease in the immunocompromised host than in the immunocompetent host.