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Shaik MR, Shaik NA, Mikdashi J. Autoimmune Dysphagia Related to Rheumatologic Disorders: A Focused Review on Diagnosis and Treatment. Cureus 2023; 15:e41883. [PMID: 37581141 PMCID: PMC10423619 DOI: 10.7759/cureus.41883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/16/2023] Open
Abstract
Autoimmune dysphagia is defined as dysphagia caused by autoimmune processes affecting various components of the swallowing process such as muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. These autoimmune causes can be classified into gastroenterological, dermatological, rheumatologic, and neurologic. Rheumatological disorders, such as scleroderma, Sjogren's syndrome, systemic lupus erythematosus, rheumatoid arthritis, sarcoidosis, Behcet's disease, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, or granulomatosis with polyangiitis, have been associated with dysphagia. Autoimmune dysphagia in the context of rheumatological disorders is particularly significant because it can occur as a sole manifestation or as part of a symptom complex associated with the underlying disorder and often responds to immunosuppressive therapies. However, diagnosing autoimmune dysphagia can be challenging as it requires the exclusion of structural and primary motility disorders through procedures such as endoscopy and manometry. Early diagnosis is important to improve the quality of life and prevent significant mortality and morbidity. Management focuses on treating the underlying disease activity, and a multidisciplinary approach involving various medical specialties may be necessary to achieve success. This article aims to review the autoimmune rheumatological conditions that can lead to dysphagia and discuss the associated pathophysiological mechanisms. We also outline the clinical clues and laboratory testing methods that facilitate early diagnosis, with the goal of improving patient outcomes through timely intervention and appropriate management.
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Affiliation(s)
- Mohammed Rifat Shaik
- Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, USA
| | - Nishat Anjum Shaik
- Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, USA
| | - Jamal Mikdashi
- Division of Rheumatology and Clinical Immunology, University of Maryland School of Medicine, Baltimore, USA
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2
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Maulahela H, Fauzi A, Renaldi K, Srisantoso QP, Jasmine A. Current role of endoscopic ultrasound for gastrointestinal and abdominal tuberculosis. JGH Open 2022; 6:745-753. [PMID: 36406654 PMCID: PMC9667406 DOI: 10.1002/jgh3.12823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/10/2022] [Accepted: 09/15/2022] [Indexed: 11/26/2022]
Abstract
A high incidence of tuberculosis (TB), especially in endemic countries, makes this infectious disease a concern. Abdominal TB contributes to 10% of extrapulmonary TB. Due to nonspecific clinical, radiological, and endoscopic findings, diagnosing abdominal TB continues to be a challenge. Hence, a precise diagnosis is needed. The diagnosis of gastrointestinal disease using endoscopic ultrasound (EUS) is often performed due to its high resolution and ability to provide a real‐time visual representation of the gastrointestinal tract and extramural structures. EUS‐guided fine‐needle aspiration (FNA) and fine‐needle biopsy (FNB) have helped diagnose TB as they offer an adequate specimen for cytology or histopathological examination. This method is considered safer, more effective, and more efficient. The capacity of EUS to diagnose abdominal TB based on the affected organs was examined via a literature search. We reviewed the role of EUS in diagnosing esophageal, gastric, pancreatic, peripancreatic, hepatosplenic, peritoneal, and intestinal TB. Generally, EUS aids in diagnosing abdominal TB. In some organs, it is superior to other diagnostic modalities. However, further examinations, such as cytology or histopathology and microbial, are still needed. We also studied the roles of EUS‐FNA and EUS‐FNB. EUS‐FNA has shown a high diagnostic yield in esophageal (94.3–100%), pancreatic and peripancreatic (76.2%), and intestinal TB (84.1%). As minimally invasive methods, EUS‐FNA and EUS‐FNB can successfully provide sufficient samples. EUS is a functional diagnostic modality for abdominal TB. EUS‐FNA and EUS‐FNB provide sufficient samples safely and efficiently for further cytology, histopathology, and microbial examinations.
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Affiliation(s)
- Hasan Maulahela
- Division of Gastroenterology, Pancreatobiliary, and Digestive Endoscopy, Internal Medicine Department Faculty of Medicine Universitas Indonesia‐Cipto Mangunkusumo National Central General Hospital Jakarta Indonesia
| | - Achmad Fauzi
- Division of Gastroenterology, Pancreatobiliary, and Digestive Endoscopy, Internal Medicine Department Faculty of Medicine Universitas Indonesia‐Cipto Mangunkusumo National Central General Hospital Jakarta Indonesia
| | - Kaka Renaldi
- Division of Gastroenterology, Pancreatobiliary, and Digestive Endoscopy, Internal Medicine Department Faculty of Medicine Universitas Indonesia‐Cipto Mangunkusumo National Central General Hospital Jakarta Indonesia
| | | | - Amirah Jasmine
- Faculty of Medicine University of Indonesia Jakarta Indonesia
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3
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DiSilvio FA, Coe SC, Bach SE, Petruzzelli GJ. Unique Cause of Dysphagia in a Patient With Remitted Sarcoidosis. JAMA Otolaryngol Head Neck Surg 2022; 148:791-792. [PMID: 35771534 DOI: 10.1001/jamaoto.2022.1586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Frank A DiSilvio
- Department of General Surgery, University of Illinois College of Medicine at Peoria, Peoria
| | - Sarah C Coe
- Department of General Surgery, McLaren Macomb Hospital, Mt Clemens, Michigan
| | - Sarah E Bach
- Department of Pathology, OSF St Francis Medical Center, Peoria, Illinois
| | - Guy J Petruzzelli
- Department of General Surgery, University of Illinois College of Medicine at Peoria, Peoria
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4
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Dysphagia, an uncommon initial presentation of sarcoidosis. Respir Med Case Rep 2022; 37:101647. [PMID: 35494553 PMCID: PMC9048080 DOI: 10.1016/j.rmcr.2022.101647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 03/23/2022] [Accepted: 03/30/2022] [Indexed: 11/20/2022] Open
Abstract
Sarcoidosis is a systemic inflammatory disease of unknown etiology with a myriad of clinical presentations depending on the organ systems involved. Neurosarcoidosis is an uncommon entity which is characterized by non-caseating granuloma infiltration of the central nervous system. Dysphagia in sarcoidosis is even more uncommon, and can involve one or more pathophysiological mechanisms: central nervous system involvement (cranial nerves associated with swallowing), lower motor neuron involvement (invasion of the enteric nervous plexus), direct muscle infiltration (invasion of the skeletal muscle portion of the esophagus and posterior pharynx), or mechanical obstruction (extrinsic compression by mediastinal lymph nodes). We report a case of a middle-aged woman presenting with severe dysphagia due to neurosarcoidosis which markedly improved after starting corticosteroids. The purpose of this case report is to highlight an atypical presentation of this disease.
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Sarcoidosis: a Rare Cause of Dysphagia. Indian J Surg 2021. [DOI: 10.1007/s12262-021-03186-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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6
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Okamura M, Hamaguchi M, Suzuki K, Nakamura T, Fujita H, Hirata K. [A patient with neurosarcoidosis presenting with easy falling and dysphagia]. Rinsho Shinkeigaku 2020; 60:346-350. [PMID: 32307397 DOI: 10.5692/clinicalneurol.cn-001404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
A 68-year-old woman was referred to our hospital for progressive dizziness, gait disturbances and weight loss for 18 months. The patient was alert and showed dysphagia and a marked tendency to fall backward. Electronystagmography showed bilateral vestibular dysfunction and audiometry showed right sensorineural hearing disturbance. Cerebrospinal fluid exam showed mononuclear pleocytosis and elevated protein levels. On 18F-FDG PET/CT, abnormal uptake was observed in the mediastinal lymph nodes, from which biopsy specimens were obtained. Histological findings showed non-caseous granuloma and a diagnosis of bilateral vestibulocochlear, glossopharyngeal and vagal nerve palsies due to neurosarcoidosis was made. Steroid therapy resulted in improvement in her clinical symptoms. Neurosarcoidosis should be included in the differential diagnosis of patients showing progressive easy falling and dysphagia.
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Primary Esophageal Tuberculosis Without Dysphagia or Odynophagia in a Patient Without HIV. ACG Case Rep J 2020; 7:e00323. [PMID: 32440526 PMCID: PMC7209795 DOI: 10.14309/crj.0000000000000323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 12/19/2019] [Indexed: 11/17/2022] Open
Abstract
We report a case of primary esophageal tuberculosis in a 35-year-old woman without HIV who presented with a month's history of epigastric and chest pain without dysphagia or odynophagia and was found to have histologic evidence of multiple caseating granulomata on esophageal biopsy, which was confirmed positive for Mycobacterium tuberculosis complex DNA and cultures.
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8
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Abstract
Involvement of the gastrointestinal (GI) tract is an infrequent extrathoracic presentation of sarcoidosis. We reviewed 305 cases of GI involvement reported in 238 patients, in whom GI sarcoidosis was the first sign of the disease in half the cases. The disease does not affect the GI tract uniformly, with a clear oral-anal gradient (80% of reported cases involved the esophagus, stomach, and duodenum). Clinicopathological mechanisms of damage may include diffuse mucosal infiltration, endoluminal exophytic lesions, involvement of the myenteric plexus, and extrinsic compressions. Ten percent of patients presented with asymptomatic or subclinical disease found on endoscopy. The diagnosis is relevant clinically because 22% of cases reviewed presented as life threatening. In addition, initial clinical/endoscopic findings may be highly suggestive of GI cancer. The therapeutic approach is heterogeneous and included wait-and-see or symptomatic approaches, glucocorticoid/immunosuppressive therapy, and surgery. Sarcoidosis of the gut is a heterogeneous, potentially life-threatening condition that requires a multidisciplinary approach and early clinical suspicion to institute personalized therapeutic management and follow-up.
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Burkitt's Lymphoma of the Gastrohepatic Omentum: A Malignant Presentation of Pseudoachalasia. Case Rep Gastrointest Med 2019; 2019:1803036. [PMID: 30733877 PMCID: PMC6348844 DOI: 10.1155/2019/1803036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 12/25/2018] [Indexed: 12/29/2022] Open
Abstract
Achalasia is an intrinsic disorder of the esophagus that results from loss of ganglion cells in the lower esophageal sphincter. Clinically it is manifested by dysphagia to solids and liquids, weight loss, regurgitation, and chest pain. Pseudoachalasia, in contrast, is a rare entity that causes identical symptoms, but has a divergent underlying pathogenesis. The symptomology in these cases oftentimes occurs secondary to extrinsic compression of the esophagus, mostly attributable to malignancy. Although many cases of extrinsic esophageal compression have been reported in the literature, rarely has this occurred secondary to Burkitt's lymphoma in an adult. Here, we present a case of Burkitt's lymphoma resulting in pseudoachalasia in a 70-year-old female. The concurrence of these two entities in one patient makes this case presentation especially rare.
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Olteanu C, Worley B, Teo I, Macdonald J. Photodistributed sarcoidosis: a case report and approach to management. SAGE Open Med Case Rep 2018; 6:2050313X18796877. [PMID: 30302250 PMCID: PMC6170962 DOI: 10.1177/2050313x18796877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Sarcoidosis is an idiopathic disease, characterized by non-caseating granulomas in multiple organs/tissues. Cutaneous involvement occurs in approximately one-quarter of patients with a wide variety of presenting morphologies. This case report describes a case of photodistributed sarcoidosis, a rare cutaneous variant, with systemic involvement. A 42-year-old man presented with a history of a pruritic, rash with photoexacerbated annular plaques along with arthralgias and bone pain. Compared to previous reports of photodistributed sarcoidosis, our case presented with annular plaques rather than papules, and there was no prior exposure to ionizing radiation. He was treated successfully with prednisone and hydroxychloroquine. It is important to include sarcoidosis in the differential of photodistributed dermatoses.
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Affiliation(s)
| | - Brandon Worley
- Division of Dermatology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Iris Teo
- Department of Pathology, University of Ottawa, Ottawa, ON, Canada
| | - Jillian Macdonald
- Division of Dermatology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Dick TM, El Hag M, Mallery JS, Amin K. Esophageal Carcinoma Cuniculatum Associated with Non-Necrotizing Granulomatous Inflammation and Lymphadenopathy: Clinicopathologic Features and Diagnostic Challenges. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:790-795. [PMID: 29973579 PMCID: PMC6064193 DOI: 10.12659/ajcr.908116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patient: Male, 52 Final Diagnosis: Carcinoma cuniculatum Symptoms: Chest discomfort • dysphagia Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Toni M Dick
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Mohamed El Hag
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - J Shawn Mallery
- Department of Gastroenterology, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Khalid Amin
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, MN, USA
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Alzaghal AA, Salman R, Berjawi G, Haddad M, Naffaa L. The short esophagus: Review of a neglected entity. Clin Imaging 2018; 50:43-50. [DOI: 10.1016/j.clinimag.2017.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 11/22/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
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13
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Patel B, Shah M, Gelaye A, Dusaj R. A complete heart block in a young male: a case report and review of literature of cardiac sarcoidosis. Heart Fail Rev 2018; 22:55-64. [PMID: 27817119 DOI: 10.1007/s10741-016-9585-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cardiac sarcoidosis is one of the uncommon causes of heart failure. Generally, it presents in the form of varying clinical manifestations ranging from asymptomatic to fatal arrhythmias such as ventricular tachycardia and complete heart block. It is difficult to make a diagnosis strictly based on clinical grounds. However, in the setting of extracardiac sarcoidosis and patients presenting with advanced heart block or ventricular arrhythmia, direct cardiac involvement should be suspected. The definitive diagnosis of cardiac sarcoidosis can be made from endomyocardial biopsy, but it is falling out of favor due to patchy myocardial involvement, considerable procedure-related risks, and advancement in additional imaging modalities. Once cardiac sarcoidosis has been diagnosed, management of the disease remains challenging. Steroids are considered the mainstay of therapy, and implantable cardioverter defibrillator therapy can be considered in a selected group of patients at greater risk for malignant ventricular arrhythmias.
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Affiliation(s)
- Brijesh Patel
- Department of Cardiology, Lehigh Valley Hospital, Allentown, PA, USA.
| | - Mahek Shah
- Department of Cardiology, Lehigh Valley Hospital, Allentown, PA, USA
| | - Alehegn Gelaye
- Department of Pulmonary and Critical Care, Providence-Providence Park Hospital, Southfield, MI, USA
| | - Raman Dusaj
- Department of Cardiology, Lehigh Valley Hospital, Allentown, PA, USA
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Inayat F, Hussain Q, Shafique K. Dysphagia Caused by Extrinsic Esophageal Compression From Mediastinal Lymphadenopathy in Patients With Sarcoidosis. Clin Gastroenterol Hepatol 2017; 15:e119-e120. [PMID: 27840183 DOI: 10.1016/j.cgh.2016.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/02/2016] [Accepted: 11/04/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Faisal Inayat
- Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical College, New York City, New York
| | - Qulsoom Hussain
- Department of Medicine, Shifa International Hospital, Shifa College of Medicine, Islamabad, Pakistan
| | - Khurram Shafique
- Department of Pathology, SUNY Downstate Medical Center, Brooklyn, New York
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15
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Di Piazza A, Vernuccio F, Costanzo M, Scopelliti L, Picone D, Midiri F, Salvaggi F, Cupido F, Galia M, Salerno S, Lo Casto A, Midiri M, Lo Re G, Lagalla R. The Videofluorographic Swallowing Study in Rheumatologic Diseases: A Comprehensive Review. Gastroenterol Res Pract 2017; 2017:7659273. [PMID: 28706536 PMCID: PMC5494561 DOI: 10.1155/2017/7659273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/11/2017] [Indexed: 02/01/2023] Open
Abstract
Autoimmune connective tissue diseases are a heterogeneous group of pathologies that affect about 10% of world population with chronic evolution in 20%-80%. Inflammation in autoimmune diseases may lead to serious damage to other organs including the gastrointestinal tract. Gastrointestinal tract involvement in these patients may also due to both a direct action of antibodies against organs and pharmacological therapies. Dysphagia is one of the most important symptom, and it is caused by failure of the swallowing function and may lead to aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. The videofluorographic swallowing study is a key diagnostic tool in the detection of swallowing disorders, allowing to make an early diagnosis and to reduce the risk of gastrointestinal and pulmonary complications. This technique helps to identify both functional and structural anomalies of the anatomic chain involved in swallowing function. The aim of this review is to systematically analyze the basis of the pathological involvement of the swallowing function for each rheumatological disease and to show the main features of the videofluorographic study that may be encountered in these patients.
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Affiliation(s)
- Ambra Di Piazza
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | | | - Massimo Costanzo
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Laura Scopelliti
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Dario Picone
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Federico Midiri
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Francesco Salvaggi
- Unit of Colorectal Surgery, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, Second University of Naples, Naples, Italy
| | - Francesco Cupido
- Department of Surgical, Oncologic and Stomatologic Diseases, University of Palermo, Palermo, Italy
| | - Massimo Galia
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Sergio Salerno
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Antonio Lo Casto
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Massimo Midiri
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Giuseppe Lo Re
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
| | - Roberto Lagalla
- Section of Radiology-Di.Bi.Med., University of Palermo, Palermo, Italy
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Attou R, Duttmann R, Devriendt A, De Bels D. Oesophageal lesions as first manifestation of necrotising sarcoid granulomatosis. BMJ Case Rep 2015; 2015:bcr-2015-209471. [PMID: 26150629 DOI: 10.1136/bcr-2015-209471] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Necrotising sarcoid granulomatosis is a rare disease associating sarcoid-like granulomas, vasculitis and necrosis in the lungs and seldom in extrapulmonary locations. We report the case of a 23-year-old woman with an initial symptom consisting of epigastric pain. Oesophagoscopy demonstrated oesophagitis. Evolution was marked by fever, dyspnoea and pulmonary lesions. The first presumptive diagnosis was Wegener disease but biopsies (of the lungs and the oesophagus) demonstrated the diagnosis of necrotising sarcoid granulomatosis. Evolution was favourable under corticoid therapy. Necrotising sarcoid granulomatosis may present as an extrapulmonary disease and is an important differential diagnosis of other disease such as Wegener disease.
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Affiliation(s)
- Rachid Attou
- Department of Intensive Care, Brugmann University Hospital, Brussels, Belgium
| | - Ruth Duttmann
- Department of Pathology, Brugmann University Hospital, Brussels, Belgium
| | - Arnaud Devriendt
- Department of Radiology, Brugmann University Hospital, Brussels, Belgium
| | - David De Bels
- Department of Intensive Care, Brugmann University Hospital, Brussels, Belgium
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Shenoy N, Tesfaye M, Brown J, Simmons N, Weiss D, Meholli M, Mabie P. Corticosteroid-resistant bulbar neurosarcoidosis responsive to intravenous immunoglobulin. Pract Neurol 2015; 15:289-92. [DOI: 10.1136/practneurol-2015-001112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2015] [Indexed: 12/13/2022]
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Abdallah T, Abdallah M, Elsayegh D, Chalhoub M, Khoueiry G, Glatman A, Maniatis T. Isolated dysphagia unmasking bulbar neurosarcoidosis and pulmonary sarcoidosis. Arab J Gastroenterol 2014; 15:85-7. [PMID: 25097053 DOI: 10.1016/j.ajg.2014.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/28/2014] [Indexed: 11/17/2022]
Abstract
Dysphagia is a rare manifestation of sarcoidosis. It is more commonly the result of esophageal compression by enlarged mediastinal lymph nodes rather than direct esophageal involvement and rarely secondary to neurosarcoidosis and oropharyngeal dysphagia. We report a 54 year old female presenting with a six month history of worsening dysphagia. She denied respiratory symptoms. Physical exam was normal. ESR was 61 mm/hr. Serum ACE level was 65 mcg/L. Chest X-ray was normal. Esophagram revealed a large amount of contrast pooling in pharyngeal recesses with intermittent laryngeal aspiration. Swallow videofluorography showed a decreased retraction of the base of the tongue, limited laryngeal elevation, and a large amount of contrast pooling in pharyngeal recesses with intermittent laryngeal aspiration. EGD showed a normal opening of the upper esophageal sphincter and the cricopharyngeus appeared normal. Proximal esophageal biopsies were normal. Brain MRI with gadolinium was normal. Lumbar puncture was performed. CSF showed a moderate pleocytosis, a WBC count of 19 with 97% lymphocytes, an elevated total protein level of 85 mg/dl (15-60). Neck CT scan showed no oropharyngeal tissue thickening or infiltration, no masses or enlarged lymph nodes. Chest CT scan showed enlarged intrathoracic lymph nodes and no esophageal compression. Bronchoscopy showed the vocal cords to be intact, and the CD4/CD8 ratio in BAL was 5.3. Subcarinal lymph node EBUS biopsy revealed non caseating granulomas. The patient was started on IV methylprednisolone. Three days later, the swallow videofluorography showed a near complete response to steroids. The patient tolerated regular consistency diet with thin liquids, and she was discharged on a slow taper of prednisone over a period of three months. A unique case of isolated dysphagia unmasking bulbar neurosarcoidosis and pulmonary sarcoidosis is herein reported.
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Affiliation(s)
- Tarek Abdallah
- Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
| | - Mokhtar Abdallah
- Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States
| | - Dany Elsayegh
- Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States
| | - Michel Chalhoub
- Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States
| | - Georges Khoueiry
- Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States
| | - Alex Glatman
- Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States
| | - Theodore Maniatis
- Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States
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