Raúl de los Ríos

Giant gastroduodenal trichobezoar: Rapunzel syndrome.

To the Editor: Bezoars are non-digestible material collections located inside the gastrointestinal tract. Th e most common are phytobezoars that are of vegetable origin. Trichobezoars are caused due to ingestion of hair associated with trichotillomania. Rapunzel syndrome is characterized by a gastric trichobezoar in which the mass goes through the pylorus extending into the small bowel and sometimes even to the colon (1,2) . A 16-year-old girl came to our outpatient clinic complaining of intermittent colicky abdominal pain located at the epigastrium accompanied by nausea and vomiting. Th ese symptoms were worsening and she had also lost her appetite and had started to lose weight as the nausea and vomiting persisted. She lost 24 kg in a year. She recalled having a craving for dirt (pica) when she was 11 years old. She was married to a much older man (more than twice her age). Her examination showed a thin girl with pallor and swollen red nail beds with no bitten nails. Th ere were no areas of alopecia on her head. In the upper abdomen, we were able to feel a nontender 5 × 10 cm hard mass with regular borders that could be moved a little. On laboratory examination, we found mild anemia (hemoglobin 11 g / dl) and severe hypoalbuminemia (1.7 g / dl). A simple abdominal X-ray showed gastric distension. We performed an upper gastroduodenal endoscopy and were able to identify an extensive mass of hair, wool, and vegetables that covered the entire stomach and duodenum to as far as we could scope ( Figure 1 ). Th e patient was transferred to the surgical ward where a laparotomy was performed, extracting a giant trichobezoar that was 120 cm long ( Figure 2 ). She had an uneventful recovery and was able to start eating again without nausea or vomiting. When evaluated by the psychiatrist, she was diagnosed with major depression and discharged with medication aft er 72 h. Trichobezoars are frequent in young women usually with a psychiatric disorder. Rapunzel syndrome has been named aft er the heroine of a German fairy tale by the Grimm Brothers. Rapunzel let her long golden hair down the tower where she was imprisoned, to allow her prince lover to climb up and rescue her (3) . Th e fi rst Rapunzel syndrome case was described by Vaughan in 1968; it is quite uncommon as there are only 33 cases reported worldwide, one of them previously in Peru (4) . Th ey are formed because of the voluntary ingestion of indigestible material. Most patients present with gastrointestinal symptoms, mainly abdominal pain, distension, nausea, vomiting, or early satiety. Diagnosis is usually carried out by endoscopy and the extraction is by open surgery, although there have been some reports with laparoscopy (5) . An adequate psychiatric assessment is important to avoid its recurrence.

Chronic Diarrhea and Pancolitis Caused by Paracoccidioidomycosis: A Case Report

South American blastomycosis is a systemic micosis caused by infection with Paracoccidioides brasiliensis. The most frequently affected sites are the lower lip buccal mucous membrane, palate, tongue, sublingual region, lymph glands, and lungs. However, colonic involvement is not a common expression of Paracoccidioidomycosis. We report a case of chronic diarrhea and pancolitis caused by Paracoccidioidomycosis with fatal outcome.

Dimorphic fungal coinfection as a cause of chronic diarrhea and pancolitis.

Histoplasma capsulatum and Paracoccidioides brasiliensis are dimorphic fungi that cause systemic mycosis mostly in tropical South America and some areas of North America. Gastrointestinal involvement is not uncommon among these fungal diseases, but coinfection has not previously been reported. We report a patient with chronic diarrhea and pancolitis caused by paracoccidioidomycosis and histoplasmosis.