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An Elderly Woman With Facial Erythema and Hematemesis
CLINICAL CHALLENGES AND IMAGES IN GI An Elderly Woman with Facial Erythema and Hematomesis Rintaro Hashimoto and Akimichi Chonan
Q3
Department of Gastroenterology, Sendai Kousei Hospital, Miyagi, Japan
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Question: A 72-year-old woman with a history of schizophrenia presented to our hospital with dysphagia and hematemesis. She had complaints of fever and painful erythema around the mouth for the past 3 days. Her vital signs were normal except body temperature, which was 38.3 C. Physical examination revealed erythema and tenderness around her mouth (Figure A) and mild epigastric tenderness. Laboratory studies showed a white cell count of 25,000 cells/mL and C-reactive protein of 22.68 mg/dL. Contrast-enhanced computed tomography scan showed diffuse wall thickening from the pharynx (Figure B) to the stomach (Figure C), indicating edematous change. Emergent upper endoscopy showed markedly edematous mucosa of the pharyngolarynx (Figure D), diffuse redness from the esophagus to the duodenal bulb (Figure E) and a large gastric erosion with coagulation at the fundus (Figure F). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.06.011
Gastroenterology 2016;-:1–2 DIS 5.4.0 DTD YGAST60517 proof 31 August 2016 9:02 am ce
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CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 3: Erysipelas Followed by Phlegmonous Esophagogastritis
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Q2
The results of culture from facial skin and gastric biopsies showed an infection of a-Streptococcus spp. We diagnosed erysipelas followed by phlegmonous esophagogastritis and started treatment with intravenous ampicillin/sulbactam for 2 weeks. She became afebrile in a few days, and erythema and tenderness around the mouth and epigastric pain completely disappeared within 1 week. Upper endoscopy on the 28 day revealed only small erosion at the fornix. Phlegmonous infection can affect any site of the gastrointestinal tract and most cases occurred only in the stomach.1 The most common pathogens are Streptococcus species, which accounts for 70% of cases. Endoscopic findings of the affected esophagus are diffuse luminal narrowing and ulcer-like lesions.2 Computed tomography findings include diffuse wall thickening with intramural low density, as in this case.1 Neither the simultaneous involvement of the pharynx, esophagus, and stomach, nor the phlegmonous infection of upper gastrointestinal followed by erysipelas has not been reported. The mortality of phlegmonous gastritis is reported relatively high (20%-50%), so early diagnosis and intervention are important.1
References 1. 2.
Kim GY, Ward J, Henessey B, et al. Phlegmonous gastritis: case report and review. Gastrointest Endosc 2005; 61:168–174. Kim HS, Hwang JH, Hong SS, et al. Acute diffuse phlegmonous esophagogastritis: a case report. J Korean Med Sci 2010; 25:1532–1535.
For submission instructions, please see the Gastroenterology website (www.gastrojournal.org).
2 DIS 5.4.0 DTD YGAST60517 proof 31 August 2016 9:02 am ce
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Q3
Department of Gastroenterology, Sendai Kousei Hospital, Miyagi, Japan
print & web 4C=FPO
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Question: A 72-year-old woman with a history of schizophrenia presented to our hospital with dysphagia and hematemesis. She had complaints of fever and painful erythema around the mouth for the past 3 days. Her vital signs were normal except body temperature, which was 38.3 C. Physical examination revealed erythema and tenderness around her mouth (Figure A) and mild epigastric tenderness. Laboratory studies showed a white cell count of 25,000 cells/mL and C-reactive protein of 22.68 mg/dL. Contrast-enhanced computed tomography scan showed diffuse wall thickening from the pharynx (Figure B) to the stomach (Figure C), indicating edematous change. Emergent upper endoscopy showed markedly edematous mucosa of the pharyngolarynx (Figure D), diffuse redness from the esophagus to the duodenal bulb (Figure E) and a large gastric erosion with coagulation at the fundus (Figure F). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.06.011
Gastroenterology 2016;-:1–2 DIS 5.4.0 DTD YGAST60517 proof 31 August 2016 9:02 am ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 3: Erysipelas Followed by Phlegmonous Esophagogastritis
print & web 4C=FPO
117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Q2
The results of culture from facial skin and gastric biopsies showed an infection of a-Streptococcus spp. We diagnosed erysipelas followed by phlegmonous esophagogastritis and started treatment with intravenous ampicillin/sulbactam for 2 weeks. She became afebrile in a few days, and erythema and tenderness around the mouth and epigastric pain completely disappeared within 1 week. Upper endoscopy on the 28 day revealed only small erosion at the fornix. Phlegmonous infection can affect any site of the gastrointestinal tract and most cases occurred only in the stomach.1 The most common pathogens are Streptococcus species, which accounts for 70% of cases. Endoscopic findings of the affected esophagus are diffuse luminal narrowing and ulcer-like lesions.2 Computed tomography findings include diffuse wall thickening with intramural low density, as in this case.1 Neither the simultaneous involvement of the pharynx, esophagus, and stomach, nor the phlegmonous infection of upper gastrointestinal followed by erysipelas has not been reported. The mortality of phlegmonous gastritis is reported relatively high (20%-50%), so early diagnosis and intervention are important.1
References 1. 2.
Kim GY, Ward J, Henessey B, et al. Phlegmonous gastritis: case report and review. Gastrointest Endosc 2005; 61:168–174. Kim HS, Hwang JH, Hong SS, et al. Acute diffuse phlegmonous esophagogastritis: a case report. J Korean Med Sci 2010; 25:1532–1535.
For submission instructions, please see the Gastroenterology website (www.gastrojournal.org).
2 DIS 5.4.0 DTD YGAST60517 proof 31 August 2016 9:02 am ce
175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232