Bobby R. Kakati

Strongyloides Duodenitis: Case Report and Review of Literature

Strongyloides stercoralis affects 30 to 100 million people worldwide and is a common cause of abdominal pain and diarrhea. Strongyloidiasis is a chronic and limited disease; however, in immunocompromised patients, hyperinfection syndrome can occur. Diagnosing strongyloidiasis early is important, as almost all deaths due to helminths in the United States are due to S stercoralis hyperinfection. Patients infected with human immunodeficiency virus (HIV) do not appear to be at an increased risk for S stercoralis hyperinfection. We report a case of an HIV-infected Hispanic woman presenting with dyspepsia, emesis, abdominal pain, and diarrhea diagnosed with S stercoralis on an esophagogastroduodenoscopy biopsy of the duodenum. The diagnostic workup had been inconclusive and deciding to biopsy the small bowel based on the nonerythematous boggy appearance of the duodenal folds was the key step in making the correct diagnosis. Early diagnosis and treatment thwarted the developing hyperinfection syndrome and likely prevented further morbidity and probably saved her life.

Extensive Extramedullary Disease Involving the Colon in Multiple Myeloma: A Case Report and Review of Literature

IntroductionOrgan involvement in multiple myeloma (MM) is characterized by infiltrative disease or by a myelomatous mass known as a plasmacytoma. We present a patient with MM who had extensive extramedullary involvement of the colon and a review of the literature on colon plasmacytomas.Case reportA 57-year-old male with MM presented with disease relapse in 2007, workup showing biopsy confirmed left perinephric extra-medullary disease involving the adjacent colon. Positron emission-tomography (PET) exhibited intense pan-colonic fluoro-deoxyglucose (FDG) uptake and computed-tomography confirmed extensive infiltrating soft tissue thickening in the ascending, transverse, and descending colon representing plasmacytomas. The patient underwent an autologous hematopoietic stem cell transplantation after conditioning with high-dose melphalan. Restaging PET-scan showed complete resolution of colonic extra-medullary plasmacytomas. Extramedullary plasmacytomas (EMP) are rare and constitute 4% of all plasma cell tumors.Discussion and ConclusionColonic plasmacytoma is an extremely rare site, with fewer than 25 cases reported in the literature. Colonic plasmacytomas have different presentations depending on the size and location. Treatment options for primary EMPs include surgical resection, radiotherapy, and chemotherapy. The primary treatment option for secondary EMP is systemic chemotherapy. This rare pan-colonic plasmacytoma, as a part of extramedullary myeloma, showed an impressive response to chemotherapy.

Colonic Perforation Following Polypectomy of a Gastrointestinal Follicular Lymphoma Masquerading as a Colon Polyp

IntroductionThe gastrointestinal (GI) tract is the predominant site for primary extranodal non-Hodgkin lymphomas (NHL), accounting for 5–10% of all extranodal disease.CaseA 74-year-old man underwent colonoscopy for a positive fecal occult blood test. Colonoscopy revealed a 3.5-cm polyp in the descending colon and was removed by snare cautery polypectomy. Post-polypectomy site showed a 0.3–0.5-cm mucosal defect. Five endoclips were applied to close the mucosal defect. The patient remained stable during subsequent intensive monitoring and never required surgical intervention. Pathology of the polyp revealed follicular lymphoma (FL) involving the lamina propria of the mucosa with extension into the submucosa. The patient had no systemic symptoms, and staging for NHL with contrast computerized tomography of the chest, abdomen, and pelvis revealed no evidence suggestive of lymphoma.DiscussionApproximately 6–20% of all primary GI-NHL are in the colon. The frequency of GI-FL accounts for 1–3.6% of all GI-NHL. After a search of the current literature, there have been no cases of a follicular lymphoma presenting solely as an isolated colon polyp. Likewise, bowel perforation due to polypectomy of such polyps has never been cited. Retrospectively, the diagnosis and extent of the polyp could have been established using endoscopic end-to-end forceps biopsy and/or endoscopic ultrasound with a radial scanning catheter probe and fine-needle aspiration of the lesion. Such a diagnosis could have changed the strategy for endoscopic removal of the polyp. Our case is interesting because it is the first report of a follicular lymphoma presenting as a single isolated colon polyp involving all layers of the colonic mucosa.

PSEUDOMELANOSIS DUODENI: A RARE FINDING FROM UPPER ENDOSCOPY

Dear Editor, A 65-year-old black woman with a history of end-stage renal disease (requiring hemodialysis), diabetes mellitus and hypertension, underwent endoscopy for work-up of anemia. Upper endoscopy revealed an abnormal dark pigmentation in the duodenal bulb and the second portion of the duodenum. Biopsies of the duodenum revealed a black granular pigment within the tips of villi. The diagnosis of pseudomelanosis duodeni was made on the basis of clinical, endoscopic and histological findings. Pseduomelanosis duodeni is an extremely rare condition not associated with a duodenal malignancy. To an endoscopist, the typical finding is a flat hyperpigmented brownish-black speckled duodenal mucosa. Histology demonstrates the accumulation of a dark pigment within the macrophages of the lamina propria. There are no cases where endoscopic hyperpigmentation was not supported by histological evidence of pseudomelanosis duodeni. The present case is being submitted for its classical endoscopy and histological findings. A 65-year-old black woman with a history of end-stage renal disease (requiring hemodialysis), diabetes mellitus, hypertension, and hypothyroidism was referred to our clinic for anemia. The patient was on multiple medications, including zolpidem, aspirin, clonidine, hydralazine, insulin, levothyroxine, and metoprolol. Upper endoscopy revealed an abnormal dark pigmentation in the duodenal bulb and the second portion of the duodenum (Fig. 1). Biopsies of the duodenum were taken, and histology revealed a black granular pigment within the tips of villi, which was negative for iron (Fig. 2). The diagnosis of pseudomelanosis duodeni was made on the basis of clinical, endoscopic and histological findings. Pseduomelanosis duodeni is an extremely rare, benign condition first described by Bisordi and Kleinman in 1976. To an endoscopist, the typical finding is a flat hyperpigmented brownish-black speckled duodenal mucosa. Histology unequivocally demonstrates the accumulation of a dark pigment within the macrophages of the lamina propria.There are no cases where endoscopic hyperpigmentation was not supported by histological evidence of pseudomelanosis duodeni; however, there are cases in which biopsies of a normal-appearing duodenum have disclosed pseudomelanosis duodeni histologically. Review of the literature shows that pseudomelanosis duodeni usually occurs in women older than 60 years of age and rarely occurs in a setting other than chronic renal failure, arterial hypertension, and/or diabetes mellitus. Consequently, certain medications (e.g. ferrous sulfate, hydralazine, propanolol, hydrochlorothiazide, furosemide) have been associated with this condition. The brownish-black pigment is mainly ferrous sulfide with small amounts of other elements. The source and pathogenesis of pigment deposition exclusively in the duodenal mucosa and the prognostic implications of pseudomelanosis duodeni are unknown. There has been no documented fibrosis, duodenitis, stricture formation or ulceration described in the literature. Hence, the significance of such finding, prognosis, and guidelines regarding endoscopic surveillance have not been determined.

Percutaneous transhepatic cholangioscopy using a flexible digital ureteroscope through a 10-fr vascular sheath: a novel method to evaluate bile duct injury in patients with Roux-en-Y gastric bypass surgery.

Patients with long afferent limb Roux-en-Y gastric bypass (RYGB) surgery represent a subset of patients in whom endoscopic management of bile duct pathology is challenging. We describe a 53-year-old woman with long afferent limb RYGB surgery for weight loss who presented with worsening abdominal pain 2 weeks after computed tomography (CT)guided biopsy of pancreatic head fullness. An inadvertent common bile duct (CBD) injury resulting in bile duct leak was confirmed on nuclear scan. A subsequent percutaneous transhepatic cholangiogram (PTC) revealed moderate intrahepatic and extrahepatic biliary duct dilatation with CBD stricture distal to the cystic duct (Fig. 1). We used the technique of percutaneous cholangioscopy (PCS) using an Invisio DUR-D flexible digital ureteroscope (FDU) from Gyrus ACMI (Southborough, MA, USA) (Fig. 2) through a 10-Fr vascular sheath to successfully evaluate and biopsy the CBD at the site of the stricture and ampulla (Video S1). This scope has a 65-cm working length with a diameter of between 8.7 Fr at the tip to 9.3 Fr at the shaft. It has a 3.6-Fr working channel that allows the use of instruments such as biopsy forceps, laser fibers and baskets up to 3 Fr, while still permitting adequate irrigation. The tip houses dual LED-driven light carriers and a 1-mm digital camera that eliminates the need for fragile fiber optics. The scope is capable of dual 250 degrees of deflection which improves maneuverability. The images by this ureteroscope can be digitally magnified to 135% and have a higher resolution of effective pixel counts, 12-fold fiberoptic scopes. PCS using DFU provides many advantages over peroral and percutaneous fiberoptics cholangioscopy; the use of a vascular sheath to access the bile duct percutaneously eliminates the need for fistula maturation as required in endoscopic retrograde cholangiopancreatography through a gastrostomy tract. It provides a means to irrigate the bile duct which improves the visual field. Digital flexible ureteroscopes are more durable and maneuverable than fiberoptic cholangioscopes and provide better-quality imaging.

Rare Case of Dysphagia

Wound botulism is exceedingly rare and occurs almost exclusively among injection drug users. In 2008 there was a case of wound botulism in a noninjecting drug user reported to the Centers for Disease Control and Prevention (CDC). We report a case of a Caucasian male developing dysphagia due to wound botulism after having a motorcycle accident that left him with open fractures. The CDC was contacted and the patient was transferred to medical intensive care unit to be emergently started on hepatavalent Clostridium botulinum antitoxin. Early suspicion of wound botulism is essential for effective therapy with antitoxin in this life-threatening disease. If not suspected, this patient would likely have died. Nevertheless, the delay in diagnosis and treatment resulted in the patient’s suffering dysphagia and neurological deficits. The patient required a percutaneous endoscopic gastrostomy tube and months of dysphagia therapy, supportive care, and rehabilitation. Our aim is to increase the awareness for wound botulism when a patient presents with dysphagia and diplopia after suffering open wounds. If suspected early, the morbidity and mortality from this disease can be prevented.