Ricardo Veloso

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.

Tarlov cysts: an unusual case of perianal pain

A 74-year-old man with no relevant personal history, presented to our outpatient gastroenterology practice with complaints of perianal pain for 2 months. The pain was dull and was intensified by movement and local pressure. No relieving factors or association with other symptoms were identified. According to the patient related, the onset of symptoms was associated with a transrectal ultrasoundguided prostate biopsy that he had previously undergone. There were no abnormal findings on physical examination or on colonoscopy. Magnetic resonance imaging of the lumbosacral spine identified two cystic formations, 5 and 12 mm in diameter in the sacral region of the spinal canal (Fig. 1), which were classified as Tarlov cysts. The patient was treated symptomatically for his lumbar pain with nonsteroidal anti-inflammatory drugs and analgesics and was later referred for a neurosurgery consultation for further evaluation and treatment. Tarlov or perineural cysts are extradural meningeal dilations arising from the posterior spinal nerve near the dorsal root ganglion. The cysts are usually asymptomatic and in most cases are diagnosed as an incidental finding [1]. The real prevalence of these structures in the adult population is estimated to be between 4.6 and 9 % [2]. These structures that have been found at all levels of the spinal medulla are most common in the sacral region, especially at the S2/S3 level. Usually, they are multiple and bilateral. Tarlov cysts are usually clinically insignificant. Nevertheless, due to pressure exerted on nerve tissue and bone, they can become symptomatic. Symptoms like lumbar pain, sciatic nerve pain, neurogenic claudication, paraesthesia of the lower extremities, muscular weakness, genitourinary changes (e.g. functional impotence and urinary incontinence) or gastrointestinal symptoms (e.g. perianal pain and changes in bowel habits) have been reported. The growing use of radiological imaging has made possible a more frequent identification of these structures. Magnetic resonance imaging is the gold-standard for diagnosing Tarlov cysts. Fig. 1 T1 weighted magnetic resonance image showing a 12-mm Tarlov cyst

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