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A case of CMV colitis in an immunocompetent host
AJG – September, Suppl., 2001
removing large foreign bodies of irregular shape from the upper gastrointestinal tract need to be prepared to utilize additional instruments such as a laryngoscope. Bibliography: 1. Faust J, Schreiner O. A swallowed toothbrush. Lancet 2001; 357: 1014. 2. Riddlesberger MM Jr, Cohen HL, Glick PL. The swallowed toothbrush: a radiographic clue of bulimia. Pediatr Radiol 1991; 21: 262– 64. 3. Nagashima R, Saitoh H, Fukase Y, et al. Endoscopic removal of a toothbrush using biopsy forceps and thread. Endoscopy 1998; 30: S90 –1.
776 A rare case of a primary large cell neuroendocrine carcinoma of the colon (LCNEC) Aniq Shaikh and Martin E. Avalos*. 1Division of Digestive Diseases and Nutrition, University of South Florida College of Medicine, Tampa, Florida, United States; and 2Division of Digestive Diseases and Nutrition, VA Medical Center, Tampa, Florida, United States. Purpose: Large cell neuroendocrine carcinomas(LCNEC) are rare. Travis et al in 1991, described for the first time the so called large cell variant of high grade neuroendocrine (NE) carcinomas in the lungs. In 1999, the WHO revised the international classification of tumors and categorized them as a sub-type of large cell carcinomas. LCNEC are defined by: 1) light microscopy with neuroendocrine(NE)features such as organoid, palisading, trabecular or rossette like patterns; 2) with features of a non-small cell lung carcinoma (NSCLC)such as large size, ample cytoplasm and prominent nucleoli; 3) with a mitotic rate greater than 10X high power field; 4) with coagulation necrosis and by 5) NE immunohistochemistry or electron microscopy. LCNEC has been noted to have features of NSCLC such as adenocarcinoma and squamous cell carcinoma (SCC) and therefore these tumors are considered biologically similar to LCNEC. There is no specific therapy for LCNEC and most protocols treat them as NSCLC. LCNEC has been reported in various areas including the stomuch, gall bladder, lungs, urinary bladder and prostate. While NE carcinomas have been reported in the colon, a LCNEC involving the colon has never been reported. Case Report: A 72 years old white man was evaluated due to complaints of painless hematochezia and was found with a filling defect measuring 1.5 ⫻ 2.0 cm in the rectosigmoid area by air contrast barium enema. A colonoscopy was performed showing a 2.5 cms pale appearing, sessile polyp in the rectosigmoid area. Piecemeal polypectomy was performed. Biopsy revealed a LCNEC arising within a villous adenoma. Histologic analysis showed undifferentiated cells with scant cytoplasm, moderately large nuclei, diffuse chromatin and variably sized nucleoli with nuclear molding and a high mitotic rate as well as considerable individual cell nerosis. Immunostains were also compatible with a poorly differentiated LCNEC. CT scans of the chest, abdomen and pelvis were negative for distant metastasis. An octreotide scan was also negative for evidence of metastatic disease. The patient underwent surgical resection of the rectosigmoid colon with findings of LCNEC confined to the muscularis propria with tumor free surgical margins and 5 out of 8 positive involved lymph nodes. The patient was advised treatment with adjuvent chemotherapy and radiation therapy. Conclusions: We described a rare case of a primary LCNEC of the rectosigmoid colon, which to the best of our knowledge has not been previously described in the literature. Radiologic, endoscopic and histologic documentation is provided.
777 A case of CMV colitis in an immunocompetent host Nirmala Shanmugam UM, Rafael Amaro UM and Arvey I Rogers UM*. 1 Division of Gastroenterology, University of Miami School of Medicine, Miami, FL, United States; 2Division of Gastroenterology, University of Miami, Miami, FL, United States; and 3Division of Gastroenterology, University of Miami School of Medicine, Miami, FL, United States.
Abstracts
S243
Purpose: Infection by Cytomegalovirus (CMV) is rarely seen in an immunocompetent host. We report a case of CMV colitis in an otherwise well, immunocompetent individual. Methods: A 70-year-old man presented with intermittent bloody stools and right lower quadrant abdominal pain for one week. He was well until two months prior when he developed fever, diarrhea and abdominal pain and was diagnosed with viral gastroenteritis. His past medical history was significant for hypertension and glaucoma. Due to persistent abdominal pain a CT scan of the abdomen was done which revealed thickening of the ascending colon with mesenteric stranding. He was treated for presumptive diverticulitis with antibiotics leading to a temporary resolution of his symptoms. A follow up colonoscopy 4 weeks later showed a large ulcer within a deformed and contracted cecum. Biopsies of the ulcer were non diagnostic. Patient was admitted to further evaluate the abdominal pain and hematochezia. He was afebrile and normotensive on admission. Abdominal examination was benign with no tenderness or palpable masses. Rectal examination revealed hemoccult positive brown stools. Hemoglobin on admission was 11 g/dl and mean corpuscular volume was 85. An ulcerated cone shaped cecum was seen on repeat colonoscopy. The ileocecal valve was edematous but the terminal ileum appeared to have a normal mucosa. The rest of the colonic mucosa appeared normal. Biopsies of the ulcer edge revealed large cells containing intranuclear inclusions characteristic of CMV infection. Serology and viral cultures of the tissue were also positive for active CMV infection. HIV test was negative and the CD4 count was normal. The patient was treated with Gancyclovir with complete resolution of his symptoms. At six month follow up the patient remains asymptomatic. Conclusions: CMV rarely presents with clinically significant disease in immunocompetent individuals. CMV infection of the colon may lead to mucosal and submucosal ulcerations which may manifest as bloody diarrhea. A high index of suspicion is needed to make an appropriate diagnosis and start adequate therapy to avoid complications.
778 A case of strongyloidiasis hyperinfection and HTLV I associated GI lymphoma presenting as intractable diarrhea— case report Nirmala Shanmugam UM, Ronald Concha UM and Arvey I Rogers UM*. 1Division of Gastroenterology, University of Miami School of Medicine, Miami, Fl, United States; 2Division of Gastroenterology, University of Miami School of Medicine, Miami, FL, United States; and 3 Division of Gastroenterlogy, University of Miami School of Medicine, Miami, Fl, United States. Purpose: Human T-cell lymphotropic virus type 1 (HTLV-I) infection is recognized to be the cause of adult T-cell leukemia/lymphoma (ATLL). ATLL often presents with leukemic picture and nodal involvement, but the stomach and small intestine has rarely been reported as the primary site of involvement in ATLL. We present a case of HTLV I associated GI lymphoma complicated by Strongyloides Stercoralis hyperinfection. A 16 yr. old Haitian female living in the U.S for the last 14 years presented to our institution with four month history of persistent watery diarrhea, weight loss and vomiting. Four years prior to this presentation, she had a similar episode of diarrhea associated with hypoalbuminemia and protein-losing gastroenteropathy. Stool studies at that time revealed S.stercoralis. She recovered completely with thiabendazole therapy. Her serum albumin returned to normal levels. On physical examination, she appeared wasted. No evidence of peripheral lymphadenopathy was noted. Abdominal examination did not reveal hepatosplenomegaly, but there was mild tenderness throughout the abdomen with no rebound or guarding. She was anemic with a hemoglobin of 8 g/dl. Serum albumin was also low at (2.7g/dl). Initial stool studies, as well a flexible sigmoidoscopy were non diagnostic. To further evaluate diarrhea, the patient underwent an enteroscopy, which revealed ulcerations and thickened, edematous mucosal folds in the small bowel which were biopsied(Image to be shown). Pathology revealed a gastrointestinal T cell lymphoma, small cell variant positive for CD3, and CD5. Patient also tested
removing large foreign bodies of irregular shape from the upper gastrointestinal tract need to be prepared to utilize additional instruments such as a laryngoscope. Bibliography: 1. Faust J, Schreiner O. A swallowed toothbrush. Lancet 2001; 357: 1014. 2. Riddlesberger MM Jr, Cohen HL, Glick PL. The swallowed toothbrush: a radiographic clue of bulimia. Pediatr Radiol 1991; 21: 262– 64. 3. Nagashima R, Saitoh H, Fukase Y, et al. Endoscopic removal of a toothbrush using biopsy forceps and thread. Endoscopy 1998; 30: S90 –1.
776 A rare case of a primary large cell neuroendocrine carcinoma of the colon (LCNEC) Aniq Shaikh and Martin E. Avalos*. 1Division of Digestive Diseases and Nutrition, University of South Florida College of Medicine, Tampa, Florida, United States; and 2Division of Digestive Diseases and Nutrition, VA Medical Center, Tampa, Florida, United States. Purpose: Large cell neuroendocrine carcinomas(LCNEC) are rare. Travis et al in 1991, described for the first time the so called large cell variant of high grade neuroendocrine (NE) carcinomas in the lungs. In 1999, the WHO revised the international classification of tumors and categorized them as a sub-type of large cell carcinomas. LCNEC are defined by: 1) light microscopy with neuroendocrine(NE)features such as organoid, palisading, trabecular or rossette like patterns; 2) with features of a non-small cell lung carcinoma (NSCLC)such as large size, ample cytoplasm and prominent nucleoli; 3) with a mitotic rate greater than 10X high power field; 4) with coagulation necrosis and by 5) NE immunohistochemistry or electron microscopy. LCNEC has been noted to have features of NSCLC such as adenocarcinoma and squamous cell carcinoma (SCC) and therefore these tumors are considered biologically similar to LCNEC. There is no specific therapy for LCNEC and most protocols treat them as NSCLC. LCNEC has been reported in various areas including the stomuch, gall bladder, lungs, urinary bladder and prostate. While NE carcinomas have been reported in the colon, a LCNEC involving the colon has never been reported. Case Report: A 72 years old white man was evaluated due to complaints of painless hematochezia and was found with a filling defect measuring 1.5 ⫻ 2.0 cm in the rectosigmoid area by air contrast barium enema. A colonoscopy was performed showing a 2.5 cms pale appearing, sessile polyp in the rectosigmoid area. Piecemeal polypectomy was performed. Biopsy revealed a LCNEC arising within a villous adenoma. Histologic analysis showed undifferentiated cells with scant cytoplasm, moderately large nuclei, diffuse chromatin and variably sized nucleoli with nuclear molding and a high mitotic rate as well as considerable individual cell nerosis. Immunostains were also compatible with a poorly differentiated LCNEC. CT scans of the chest, abdomen and pelvis were negative for distant metastasis. An octreotide scan was also negative for evidence of metastatic disease. The patient underwent surgical resection of the rectosigmoid colon with findings of LCNEC confined to the muscularis propria with tumor free surgical margins and 5 out of 8 positive involved lymph nodes. The patient was advised treatment with adjuvent chemotherapy and radiation therapy. Conclusions: We described a rare case of a primary LCNEC of the rectosigmoid colon, which to the best of our knowledge has not been previously described in the literature. Radiologic, endoscopic and histologic documentation is provided.
777 A case of CMV colitis in an immunocompetent host Nirmala Shanmugam UM, Rafael Amaro UM and Arvey I Rogers UM*. 1 Division of Gastroenterology, University of Miami School of Medicine, Miami, FL, United States; 2Division of Gastroenterology, University of Miami, Miami, FL, United States; and 3Division of Gastroenterology, University of Miami School of Medicine, Miami, FL, United States.
Abstracts
S243
Purpose: Infection by Cytomegalovirus (CMV) is rarely seen in an immunocompetent host. We report a case of CMV colitis in an otherwise well, immunocompetent individual. Methods: A 70-year-old man presented with intermittent bloody stools and right lower quadrant abdominal pain for one week. He was well until two months prior when he developed fever, diarrhea and abdominal pain and was diagnosed with viral gastroenteritis. His past medical history was significant for hypertension and glaucoma. Due to persistent abdominal pain a CT scan of the abdomen was done which revealed thickening of the ascending colon with mesenteric stranding. He was treated for presumptive diverticulitis with antibiotics leading to a temporary resolution of his symptoms. A follow up colonoscopy 4 weeks later showed a large ulcer within a deformed and contracted cecum. Biopsies of the ulcer were non diagnostic. Patient was admitted to further evaluate the abdominal pain and hematochezia. He was afebrile and normotensive on admission. Abdominal examination was benign with no tenderness or palpable masses. Rectal examination revealed hemoccult positive brown stools. Hemoglobin on admission was 11 g/dl and mean corpuscular volume was 85. An ulcerated cone shaped cecum was seen on repeat colonoscopy. The ileocecal valve was edematous but the terminal ileum appeared to have a normal mucosa. The rest of the colonic mucosa appeared normal. Biopsies of the ulcer edge revealed large cells containing intranuclear inclusions characteristic of CMV infection. Serology and viral cultures of the tissue were also positive for active CMV infection. HIV test was negative and the CD4 count was normal. The patient was treated with Gancyclovir with complete resolution of his symptoms. At six month follow up the patient remains asymptomatic. Conclusions: CMV rarely presents with clinically significant disease in immunocompetent individuals. CMV infection of the colon may lead to mucosal and submucosal ulcerations which may manifest as bloody diarrhea. A high index of suspicion is needed to make an appropriate diagnosis and start adequate therapy to avoid complications.
778 A case of strongyloidiasis hyperinfection and HTLV I associated GI lymphoma presenting as intractable diarrhea— case report Nirmala Shanmugam UM, Ronald Concha UM and Arvey I Rogers UM*. 1Division of Gastroenterology, University of Miami School of Medicine, Miami, Fl, United States; 2Division of Gastroenterology, University of Miami School of Medicine, Miami, FL, United States; and 3 Division of Gastroenterlogy, University of Miami School of Medicine, Miami, Fl, United States. Purpose: Human T-cell lymphotropic virus type 1 (HTLV-I) infection is recognized to be the cause of adult T-cell leukemia/lymphoma (ATLL). ATLL often presents with leukemic picture and nodal involvement, but the stomach and small intestine has rarely been reported as the primary site of involvement in ATLL. We present a case of HTLV I associated GI lymphoma complicated by Strongyloides Stercoralis hyperinfection. A 16 yr. old Haitian female living in the U.S for the last 14 years presented to our institution with four month history of persistent watery diarrhea, weight loss and vomiting. Four years prior to this presentation, she had a similar episode of diarrhea associated with hypoalbuminemia and protein-losing gastroenteropathy. Stool studies at that time revealed S.stercoralis. She recovered completely with thiabendazole therapy. Her serum albumin returned to normal levels. On physical examination, she appeared wasted. No evidence of peripheral lymphadenopathy was noted. Abdominal examination did not reveal hepatosplenomegaly, but there was mild tenderness throughout the abdomen with no rebound or guarding. She was anemic with a hemoglobin of 8 g/dl. Serum albumin was also low at (2.7g/dl). Initial stool studies, as well a flexible sigmoidoscopy were non diagnostic. To further evaluate diarrhea, the patient underwent an enteroscopy, which revealed ulcerations and thickened, edematous mucosal folds in the small bowel which were biopsied(Image to be shown). Pathology revealed a gastrointestinal T cell lymphoma, small cell variant positive for CD3, and CD5. Patient also tested