Carol Marinho

External validation of a classification for methylene blue magnification chromoendoscopy in premalignant gastric lesions

BACKGROUND Conventional endoscopy has low sensitivity, specificity, and interobserver agreement for the diagnosis of gastric atrophy, intestinal metaplasia, and dysplasia. Magnification chromoendoscopy (ME) may optimize the evaluation of premalignant gastric lesions. OBJECTIVE AND DESIGN As part of a multicenter trial, we aimed at validating a previously proposed classification for gastric methylene blue ME at a different center. SETTING, PATIENTS, AND INTERVENTIONS: A sample of patients (n = 42) with previously diagnosed chronic atrophic gastritis with or without intestinal metaplasia underwent ME (Pentax EG-3430Z) with 1% methylene blue by 2 endoscopists. MAIN OUTCOME MEASUREMENTS A simplified version of a previously published ME classification (group I, group II [further divided into subgroups IIE and IIF], and group III) was used for macroscopic lesions (n = 203) with Sydney-Houston and Vienna classifications being used for histologic analysis (n = 479 biopsy specimens). RESULTS AND LIMITATIONS Excellent reproducibility (wK = 0.92 [95% CI, 0.88-0.96]) was observed for classification in groups and substantial reproducibility (wK = 0.78 [95% CI, 0.72-0.84]) was found for classification in subgroups. Global validity was 82% (range 78%-86%), showing no false negatives (sensitivity of 100% [1/1 biopsy]) and a very low rate of false positives (specificity 99% [297/299 biopsies]) for dysplasia detection. CONCLUSIONS This classification for methylene blue ME was highly reproducible and valid for the diagnosis of premalignant gastric lesions when used in a center different from that involved in its conception. Despite requiring an unconventional endoscope and a longer procedure, these results could reinforce ME as a valuable technique in the surveillance of patients at risk for gastric cancer.

Triple Therapy with High-Dose Proton-Pump Inhibitor, Amoxicillin, and Doxycycline Is Useless for Helicobacter pylori Eradication: A Proof-of-Concept Study

Helicobacter pylori resistance to antibiotics is steadily increasing and multidrug‐resistant strains are common and difficult to eliminate, mainly in countries where bismuth, tetracycline, furazolidone, and rifabutin are unavailable.

Primary leiomyoma of the liver: accurate preoperative diagnosis on liver biopsy

Primary leiomyoma of the liver is an exceptionally rare tumour in non-immunocompromised patients. Preoperative diagnosis of the lesion is difficult as complete imaging of this type of lesion is scarcely defined and preoperative biopsy was not the practice in previously reported cases. We report a voluminous primary leiomyoma of the liver occurring in a healthy middle-aged woman where a preoperative diagnosis was accurately achieved on biopsy. Because of its size, surgery was undertaken for exclusion of malignancy. A 16-month uneventful follow-up has been completed. We discuss the advantage of a preoperative diagnosis and propose that an imaging-guided liver biopsy should be undertaken, provided malignancy features are absent. This could prevent liver surgery merely for diagnostic purposes. Finally, we report imaging features that have not been previously described, namely on magnetic resonance imaging, which may provide an insight about the nature of this particular lesion and, advantageously, contribute toward a non-invasive diagnosis.

Proliferative glomerulonephritis with linear immunoglobulin deposition: is this atypical antiglomerular basement membrane disease?

The antiglomerular basement membrane (anti-GBM) antibody disease is marked by the presence of specific antibodies against the non-collagenous domain of the type IV collagen’s α3 chain. We describe a case of a 24-year-old Caucasian man, who may have had an atypical presentation of anti-GBM (slow progressive renal insufficiency, massive proteinuria and no detectable circulating anti-GBM antibody). The patient was treated with steroids and cyclophosphamide. This approach failed to attenuate the disease, and so rituximab was initiated with subsequent clinical improvement, normalisation of urinary sediment and marked regression of proteinuria; renal function remained stable. The renal biopsy immunofluorescence was crucial for the diagnosis.

Membranoproliferative glomerulonephritis in a puerperal with Sjögren's syndrome: Rare finding or something else?

We report on a case of a 35-year-old Caucasian woman with primary Sjögren’s Syndrome (pSS) diagnosed by salivary gland biopsy and IgM monoclonal gammopathy of undetermined significance (MGUS), treated with hydroxychloroquine 200 mg daily since she was 22 year-old. After 24 weeks into her first pregnancy, she developed marked asthenia with muscle pain and arthralgia, hypertension, oedema and palpable purpura of the lower limbs. Laboratorial testing revealed an increase in serum creatinine (sCr) (0.75 → 1.18 mg/dL), anaemia (haemoglobin (Hb) = 8.6 g/dL), active urinary sediment and nephrotic-range proteinuria (3.8 g/24 h). She was diagnosed with preeclampsia with foetal distress and underwent a caesarean at 29 weeks of pregnancy. One week post-partum the patient was discharged home with sCr = 0.84 mg/dL, Hb = 12 g/dL, 24-hour proteinuria = 1.4 g and normotensive under nifedipine 30 mg daily. Three months post-partum, she was admitted to the emergency room presenting acute pulmonary oedema requiring invasive ventilatory support. Pulmonary auscultation showed fine crackles over both lung bases, she had moderate peripheral oedema and after urinary catheterization, oligoanuria was confirmed. Laboratory tests revealed sCr = 4.39 mg/dL, K+ = 6.6 mmol/L, brain natriuretic peptide = 5013 pg/mL, Hb = 8.1 g/dL, platelet count = 248x109/L and negative blood cultures. Urinalysis showed 3+ proteinuria on a dipstick test. On echocardiogram there were no signs of endocarditis and she had a ventricular ejection fraction of 50%, renal ultrasound revealed normal kidneys and chest X-ray showed large bilateral pleural effusion. Continuous haemodiafiltration was initiated and the patient was admitted to the intensive care unit, until she gained ventilatory autonomy and suspended haemodiafiltration, being transferred to the Nephrology Department three days later for continued care. A kidney biopsy was performed revealing type I membranoproliferative glomerulonephritis with IgM (++), IgG (+) and C3 (++) deposits, glomerular capillary endotheliosis, focal and segmental thrombotic microangiopathy, tubulointerstitial nephritis and injuries of focal and discrete vasculitis. (Fig. 1). Serologies for human immunodeficiency virus, hepatitis B virus and hepatitis C virus (HCV) were negative, as well as HCV RNA testing. Complement study showed low C4 (C4<0,01) and normal C3 (C3=1,36) and high rheumatoid factor (195 IU/mL; N = ). Cryoglobulins were positive with polyclonal IgG and monoclonal IgM and kappa light chains. The patient was treated with 1 g methylprednisolone pulses on three consecutive days and subsequent oral prednisolone at a dosage of 1 mg/kg/day. One year has passed and the patient has been weaned off steroid therapy maintaining clinical stability. Analytically, the values of sCr have stabilized at 1.0 mg/dL, with proteinuria of 150 mg/24 h (Table 1). The histological findings of our patients’ kidney biopsy revealed distinct injury patterns that could be inserted in various clinical pictures: glomerular capillary endotheliosis and focal and segmental thrombotic microangiopathy were expected in the context of previous preeclampsia1 while tubulointerstitial nephritis with injuries of vasculitis were compatible with pSS.2 Regarding the immune complex mediated MPGN, which might have been the cause of acute kidney injury, the differential diagnosis of its underlying cause was challenging and included autoimmune diseases, chronic infection and monoclonal gammopathy. MPGN associated with autoimmune diseases is rarely seen in patients with SS and we also excluded chronic infection. Considering monoclonal gammopathies, although the immunofluorescence microscopy on renal biopsy was not typical, our patient was diagnosed with IgM MGUS.3 A growing number of pathologic renal conditions are being attributed to a clonal plasma cell disorder that is less myeloma-like and more MGUS-like in terms of its bulk and proliferative rate and the term monoclonal gammopathy of

Invasive bladder urothelial carcinoma, plasmacytoid variant: case report

Invasive bladder urothelial carcinoma, plasmacytoid variant is a rare entity with scarce cases reported in the literature. We report a case of a 79 years old male, subjected to transurethral resection of bladder tumor, which histological examination revealed a pT1 high-grade urothelial carcinoma. Subsequently, he underwent radical cystoprostatectomy, which showed urothelial carcinoma with lack of cohesion, plasmacytoid variant, positive for citokeratin 7 (CK7), citokeratin 20 (CK20) and trans-acting T-cell-specific transcription factor (GATA-3), and negative for E-cadherin and CD138. It is important to recognize the plasmacytoid variant of the invasive urothelial carcinoma, since it avoids a potential misdiagnosis of metastatic cancer.