Ahmed Benkirane

Irreversible Anterior Ischemic Optic Neuropathy Complicating Interferon Alpha and Ribaverin Therapy

Ophthalmologic complications with interferon therapy are rare and usually reversible. The anterior ischemic optic neuropathy is an uncommon complication of interferon treatment. A case of irreversible anterior ischemic optic neuropathy complicating interferon therapy for chronic hepatitis C is reported. We suggest that periodic ophthalmological examinations, including visual acuity and fundus examinations, should be performed to patients with high risk of ocular complications after starting and during treatment. We also suggest that an ophthalmologist would be able to detect these complications. Antiviral treatment should be stopped immediately if severe ophthalmologic complications occur.

Medial Pancreatectomy for a Neuroendocrine Tumor Invading the Splenic Artery and Vein

CONTEXT Pancreatic tumors in the midportion have traditionally been treated by an extended right or left pancreatectomy. A medial or central pancreatectomy is an alternative technique for benign or low-grade malignant neoplasms located to the left of the gastroduodenal artery and close to the splenomesenteric confluence. CASE REPORT A 38-year-old woman with no previous surgical history presented with epigastric abdominal pain. A computed tomography scan showed a 4 cm heterogeneous lesion within the pancreatic body. This tumor invaded the splenic artery and vein. There was no postoperative diabetes mellitus or exocrine insufficiency. The patient continues to be well after a 10-month follow-up without pancreatic insufficiency or local recurrence, and CT has demonstrated splenic perfusion by the collateral vessels. CONCLUSION We believe that a medial or central pancreatectomy may be a safe procedure where there is involvement of the large splenic vessels by a low grade malignant pancreatic tumor and that a systematic splenectomy is not justified.

High-level primary clarithromycin resistance of Helicobacter pylori in Morocco: a prospective multicenter molecular study.

Knowledge of local antibiotic resistance is crucial to adaption of the choice of effective empirical first-line treatment for Helicobacter pylori infection. Clarithromycin is a key component of the standard triple therapy largely used worldwide and, more particularly, in Morocco. However, clarithromycin resistance has been increasing in many countries and constitutes the main risk factor for treatment failure. Clarithromycin resistance is due to point mutation in the 23S ribosomal RNA (rRNA) gene (A2142G, A2143G, and A2142C) [1,2]. The Maastricht IV consensus report for management of H. pylori infection indicates that the threshold of clarithromycin resistance at which the standard clarithromycin-based triple therapy should not be used or a clarithromycin susceptibility test should be performed is 15–20% [3]. But in many countries, like Morocco, the current prevalence of resistance remains unknown. The aim of this study was to evaluate, for the first time in Morocco, the prevalence of the primary resistance of H. pylori to clarithromycin. We conducted a prospective study (2011–2014) including 112 Moroccan patients referred for gastro-duodenal endoscopy to three University Hospitals of Rabat (Morocco) and never previously treated for H. pylori infection. Three gastric biopsies were collected: one for histology, one for urease test, and one for molecular detection of H. pylori and the mutations in 23S rRNA genes that confer resistance to clarithromycin with a quadruplex real-time PCR using scorpion primers [1,2]. A patient was considered infected with H. pylori when at least two of the three tests were positive. Included patients were 58 (52%) men and 54 (48%) women aged from 19 to 86 years (mean 46.1 years). Sex ratio and mean age were not statistically different in the three inclusion centers. Histology detected H. pylori in 80 biopsies (71.4%). The urease test was positive for 73 biopsies (65.1%). The Scorpion PCR detected H. pylori DNA in 78 biopsies (69.6%). Considering the definition of H. pylori infection (at least two of the three tests positive), the infection rate was 69.6% (78/112). Patients with ulcer disease (27) were all except one infected by H. pylori. Infection rate was not significantly different regarding gender or inclusion center. Infected patients were statistically older (48.2 years) than noninfected patients (41.1 years) (p < 0.01). A mutation conferring resistance to clarithromycin was detected in 22 of the 78 positive samples. The prevalence of primary resistance of H. pylori to clarithromycin in this Moroccan population was 28.2%. Women were statistically more frequently infected with a resistant strain than men (38% vs 18%, p = 0.044). Among the 22 biopsies detected positive for H. pylori by Scorpion PCR, 15 (68%) harbored a A2142G mutation, 6 (27%) a A2143G mutation, and 2 (9%) a A2142C mutation, with one biopsy harboring a mixture of both A2142G and A2143G mutations. In 16 (77%) biopsies, Scorpion PCR revealed a mixed infection (detection of a susceptible and a resistant strain). We are the first to report in Morocco a resistance rate reaching 28.2%, largely over the 15–20% threshold put forward by the Maastricht IV consensus report as a reason to abandon the clarithromycin-based firstline treatment [3]. In Maghreb, such data are scarce, and the only published work, a multicenter prospective study conducted from 2005 to 2007 in Tunisia, reported a prevalence of primary resistance to clarithromycin reaching 15.4% [4]. Two recent clinical trials conducted in Morocco suggested a high rate of clarithromycin resistance. The first, conducted in 2009, showed eradication rates lower than 80% for clarithromycin-based triple therapy (ITT 78.2, PP 79.6) and the second, conducted in 2012, showed a decline in the eradication rates achieved by this regimen (ITT 65.9, PP 71), thereby suggesting an increase of the resistance rate to clarithromycin [5,6]. In conclusion, we report a high level of primary clarithromycin resistance in the Moroccan population (28.2%), which leads us to recommend abandonment of standard clarithromycin-based triple therapy as a first-line treatment.

Successful surgical treatment of extrahepatic biliary papillomatosis diagnosed with endoscopic retrograde cholangiopancreatography: a case report.

IntroductionBiliary papillomatosis is a condition characterized by multiple papillary tumors of variable distribution and extent within the biliary tract. Papillary carcinoma can develop in these lesions. It is a rare biliary pathological entity and its clinical features and outcome are not well known.Case presentationWe experienced a case of biliary papillomatosis in a 51-year-old North African man who presented with obstructive jaundice. Laboratory tests showed elevated bilirubin, alkaline phosphatase and gamma-glutamyl transpeptidase levels. Imaging (ultrasound and magnetic resonance imaging) was suggestive of Klatskin tumor associated to common bile duct stones. After endoscopic retrograde cholangiopancreatography, a balloon sweep retrieved friable tissue from his bile ducts. Histology demonstrated papillary adenomatous proliferation showing high-grade dysplasia and he was referred for surgical management.ConclusionsAlthough biliary papillomatosis is rare, it is a premalignant condition that should be well known and considered in all diagnoses of obstructive jaundice. We report a new case of biliary papillomatosis and highlight the contribution of endoscopic retrograde cholangiopancreatography in the diagnosis of this condition.

Gastric bronchogenic cyst presenting as a submucosal mass: a case report

IntroductionBronchogenic cysts are developmental anomalies of the primitive foregut which mostly occur in the lung. Gastric bronchogenic cysts are extremely rare; few cases have been reported in the literature and the diagnosis was often made following surgical resection.Case presentationA 40-year-old North African man was admitted to our hospital with a gastric submucosal mass. An endoscopic ultrasound revealed a unilocular cystic mass located in the muscular layer. Its content was echogenic suggestive of mucus. Magnetic resonance imaging confirmed the liquid nature of the cyst and showed a high ratio of proteins. Based on these observations, the diagnosis of bronchogenic cyst was confirmed. An endoscopic monitoring was decided rather than surgery because of the small size of the cyst and the absence of symptoms.ConclusionAlthough gastric bronchogenic cysts are rare, they should be well known and considered in all differential diagnoses of gastric tumors. We report a new case of gastric bronchogenic cyst and highlight the contribution of morphological tests that currently allow a non-invasive diagnosis.

Adenocarcinoma arising from chronic perianal crohn's disease: a case report

Malignant transformation of perineal fistula in Crohns disease has rarely been reported. We report a case of Crohns disease with recurrent perineal fistulas. A 36-year-old male, diagnosed with Crohns disease at the age of 24, developed adenocarcinoma in an anorectal fistula that had existed for years. He was treated with adjuvant chemoradiotherapy but died. A high index of suspicion and regular surveillance is recommended in chronic anorectal fistulas in Crohns disease. The shorter duration of Crohns fistulas prior to malignant degeneration necessitates an aggressive approach to rule out cancer.

Distomatose biliaire pseudotumorale diagnostiquée au cours d'une sphinctérotomie endoscopique

RésuméLa distomatose hépatique est une parasitose due à F. hepatica. Le diagnostic est souvent fait à la phase d’état devant une symptomatologie d’obstruction biliaire ou de pancréatite aiguë. Nous rapportons une observation de distomatose hépatobiliaire de forme pseudotumorale diagnostiquée devant la découverte d’une hémobilie et d’extraction de douves du parasite lors de la sphinctérotomie biliaire endoscopique. La cholangiographie rétrograde avec sphinctérotomie endoscopique a confirmé le diagnostic et a permis de traiter la distomatose en levant l’obstruction biliaire par l’évacuation des parasites.AbstractThe hepatobiliary fascioliasis is a parasitical disease caused by Fasciola hepatica. The diagnosis is often made in the phase with symptoms of biliary obstruction or acute pancreatitis. We report a case of pseudotumoral hepatobiliary fascioliasis diagnosed with the discovery of hemobilia and extraction of parasitic flukes during endoscopic biliary sphincterotomy. Retrograde cholangiopancreatography with endoscopic sphincterotomy confirmed the diagnosis and enabled treating fascioliasis by removing the biliary obstruction by removal of parasites.