Joana Pinto

Erythema induratum and chronic hepatitis C infection

Erythema induratum, or nodular vasculitis, was initially described as a type of cutaneous tuberculosis. Currently, it is considered a multifactorial syndrome of lobular panniculitis of unknown cause. An association between erythema induratum and hepatitis C virus (HCV) has been suggested in previous reports. We report the case of a 49-year-old male presenting with a 3-year history of itchy, painful red to violaceous cutaneous nodules and plaques on both legs that had been unresponsive to topical dermatologic treatments. Evaluation of persistent serum transaminase elevations led to a diagnosis of chronic hepatitis C with bridging liver fibrosis. A thorough evaluation to exclude mycobacterial infection was performed, and anti-tuberculosis treatment was started based on a positive QuantiFERON test. There was no improvement in the skin lesions with this treatment. The patient then received standard antiviral therapy with pegylated interferon and ribavirin for 48 weeks. Treatment produced an early virologic response with significant improvement in the skin lesions, pain and pruritus. Six months after antiviral treatment, virologic relapse occurred without recurrence of the cutaneous lesions. There appears to be an association between erythema induratum and hepatitis C infection, probably mediated by circulating immune complexes. Interestingly, lesions improve with antiviral treatment and, as shown in this case, the effect may be sustained after stopping treatment despite virologic relapse.

Metastatic malignant melanoma of duodenum: the tip of the iceberg

A47-year-old male patient was referred to our gastroenterology department, to investigate multiple and large conglomerate mediastinal adenopathies. He reported a 6-month history of anorexia, weight loss, hoarseness, decrease in visual acuity, and several pigmented skin nodules scattered over the whole body with an average size of 2 cm. More recently, he presented with diffuse abdominal pain, nausea and vomiting. Upper endoscopy showed at the duodenal bulb and second part of duodenum, several sessile erythematous polyps, between 5 and 15 mm with central ulceration (Fig. 1). The biopsy specimen revealed metastatic malignant melanoma. Immunohistochemistry stains showed neoplastic cells positive for S-100 protein (Fig. 2). Cutaneous investigation confirmed a very aggressive malignant melanoma (Fig. 3), with disseminated metastasis, including intra-orbital, thyroid, bronchial, lymphatic, heart, pancreatic, peritoneal and bone metastasis. Clinical management relied on symptomatic therapy only. PICTURES IN DIGESTIVE PATHOLOGY

Cavernous hemangiomas limited to the sigmoid colon

064 GASTROINTESTINAL ENDOSCOPY Volume 72, No. 5 : 2010 Shinichiro Yokota, MD, Department of Surgery, Kazutomo Togashi, MD, PhD, Department of Surgery, Department of Endoscopy, Naoya Kasahara, MD, Hisanaga Horie, MD, PhD, Department of Surgery, Keijiro Sunada, MD, Department of Endoscopy, Akira Tanaka, MD, PhD, Department of Pathology, Alan T. Lefor, MD, MPH, Yoshikazu Yasuda, MD, PhD, Department of Surgery, Jichi Medical University, Tochigi, Japan

A ressonância magnética cardíaca como uma mais-valia no diagnóstico etiológico de arritmias ventriculares

INTRODUCTION Cardiac magnetic resonance (CMR) imaging is increasingly important in the diagnostic work-up of a wide range of heart diseases, including those with arrhythmogenic potential. OBJECTIVE To assess the added value of CMR in etiological diagnosis of ventricular arrhythmias after an inconclusive conventional investigation. METHODS Patients undergoing CMR between 2005 and 2011 for investigation of ventricular arrhythmias were included (n=113). All had documented arrhythmias. Those with a definite diagnosis from a previous investigation and those with evidence of coronary artery disease (acute coronary syndrome, typical angina symptoms, increase in biomarkers or positive stress test) were excluded. CMR results were considered relevant when they fulfilled diagnostic criteria. RESULTS Of the 113 patients, 57.5% were male and mean age was 41.7 ± 16.2 years. Regarding the initial arrhythmia, 38.1% had ventricular fibrillation/sustained ventricular tachycardia (VF/VT) and 61.9% had less complex ventricular ectopy. CMR imaging showed criteria of a specific diagnosis in 42.5% of patients, was totally normal in 36.3%, and showed non-specific alterations in the remainder. In VF/VT patients, specific criteria were found in 60.4%, and in 31.4% of those with less complex ectopy. The most frequent diagnoses were arrhythmogenic right ventricular dysplasia, ventricular non-compaction and myopericarditis. It is worth noting that, although there was no evidence of previous coronary artery disease, 6.2% of patients had a late gadolinium enhancement distribution pattern compatible with myocardial infarction. CONCLUSION CMR gives additional and important information in the diagnostic work-up of ventricular arrhythmias after an inconclusive initial investigation. The proportion of patients with diagnostic criteria was 42.5% (60.0% in those with VF/VT), and CMR was completely normal in 36.6%.