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A CASE OF CRESCENTIC GLOMERULONEPHRITIS AND ADENOCARCINOMA OF LARGE BOWEL
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Oral Communications / European Journal of Internal Medicine 19S (2008), S1–S59
This case demonstrates a grave viral infection that is typical in situations of immunodeficiency and that should alert us to further study of pathologies associated with the immune system
TH-37 CLINICAL CASE OF CHRONIC DIARRHEA AND NON-HODGKIN’S LYMPHOMA Luís Andrade, Marco Fernandes, Ermelinda Gonçalves, Manuela Brochado. Hospital São Sebastião, Internal Medicine Department Introduction: The gastrointestinal tract is the predominant site of extranodal non-Hodgkin’s lymphomas. Primary NHLs of the GI tract are rare, accounting for only 1 to 4 percent of malignancies arising in the stomach, small intestine, or colon. In contrast, secondary GI involvement is relatively common, occurring in approximately 10 percent of patients with limited stage NHL lymphomas at the time of diagnosis, and up to 60 percent of those dying from advanced NHL. Despite their rarity, primary NHL lymphomas of the GI tract are important, since their management and prognosis are distinct from that of adenocarcinomas of the GI tract. %). The incidence is approximately 2.9/100.000 adults per year. In 40% of the situations they reveal extra-nodal involvement being the gastrointestinal tract one of the most frequent affected (75%). The management will consist of surgery and chemotherapy with survival in 5 years of 26% 73% and complete remission in 40% of the cases. Clinical case: A 42 year-old man with a Gastric Non-Hodgkin’s Lymphoma of B-cell origin, stage IIE-B diagnosed in October 2005 an submitted to a total gastrectomy and 4 cycles of QT with CHOP. In remission until October 2006, he initiated epigastric pain, weight loss, asthenia and diarrhea. Abdominal CAT scan showed a retroperitoneal adenopathy, upper gastrointestinal endoscopic was normal. Suspecting of non-Hodgkin lymphoma relapse was initiated a second line chemotherapy with ESHAP (2 cycles in December and January). The patient maintain diarrhea and he was asthenic, cachetic, desidrated with hypotension but normocardic, apiretic, pulmonary and cardiac auscultation normal, abdominal examination painless and without mass or organomegaly, moderate periphery oedema, without palpable peripherical adenopathy; Hb 7,2 g/dl (normocitic/normocromic), leucocyte 1900/ul with 1300/ul neutrophil and 500/ul lymphocite, platelet 113.000/ul; sodium 132, potassium 2,6 and magnesium 0,6 Mg mmol/l; Calcium 6,4 and phosphoru 1,9 mg/dl; total protein 2,7 and albumin 1.1 mg/dl; Fecal examination: bacteriologic and parasitologic negative Clostridium toxin difficile negative. Upper gastrointestinal endoscopy: jejunal erythema, oedema and erosion. Biopsy: enteric mucosa involvement with diffuse large B-cell non-Hodgkin lymphoma. The patient was in parentheric nutrition and one week later with correction of the analytic alteration and with better physical quality was programmed chemotherapy with ESAPH that carried through the 23/03. Three days later the patient initiated neutropenia and fever, medicated with Meropenem, Amikacin and Fluconazol but with gradual aggravation and die one week later. Conclusion: The authors present a clinical case of a sick person interned in a department of Internal Medicine.
can result in haematological malignancies as well as solid organ tumours. In our case both glomerular disease and large bowel malignancy were diagnosed more or less at the same time, raising possibility of association between ANCA positive crescentic glomerulonephritis and malignancy. Our case is also unique in being probably the first case wherein crescentic glomerulonephritis and adenocarcinoma of large bowel (signet ring cell type) has been reported. However there is need for analysis or trials looking into prevalence and association of ANCA in cancer patients
TH-39 A CASE OF EXTRAPULMONARY TUBERCULOSIS (EPT) WITH MULTIPLE BONE AND LYMPHONODAL INVOLVEMENT Alessia Rosato, Eleonora Pistella, Claudio Santini. U.O.C. Medicina Interna – Ospedale Vannini - Roma A 61 old year Indian, nun, in Italy since 40 years, was hospitalised for posterior thoracic pain and weight lost in the previous 3 months. She refers slowly resolving pneumonia 20 years ago. The temperature was 37.4°C. A painless 4 cm tender nodule was found in the left parietal area of the skull. A hard, fixed lymph node of 3 cm was palpable in the right supraclavear region. The white-cell count was 12.700/mm3, the ESR was 37 mm/hr, the C reactive protein was 3.29. Tuberculin skin test was strongly positive. Radiographs of the chest was normal. MRI scan of the thoracic spine showed a soft-tissue mass causing erosion of the anterior aspect of T4, extending to the prevertebral tissue. A total body CT scan showed multiple enlarged mediastinal and intraabdominal lymph nodes, up to 3 cm and 3 osteolytic lesions in T4, L4 and in the left parietal bone. The findings seemed suggestive for malignancy, lymphoma or multiple myeloma. Upper and lower GI endoscopy and mammography were normal. No monoclonal component was found. The excisional biopsy of the palpable supraclavear node revealed chronic granulomatous inflammation with epithelioid and giant cells, and necrotic material. A Ziehl–Neelsen stain and cultures for M. tuberculosis were negative. HIV test was negative. Four-drug antimycobacterial therapy was started. After two months she was afebrile, the thoracic pain decreased and the parietal nodule disappeared. EPT usually occurs in patients with evidence of active or previous pulmonary disease. In immunocompromised patients (primary HIV) EPT without evidence of pulmonary involvement can occur, often with impressive lymphadenopathy. In this setting, bone involvement can be multiple, rather than the characteristic picture of Pott’s disease. Our patient suggests that EPT without pulmonary involvement in immunocompetent patients represent an emergent disease and should be considered in differential diagnosis of diffuse lymphadenopathy or multiple destructive bone lesions.
TH-40 TH-38 A CASE OF CRESCENTIC GLOMERULONEPHRITIS AND ADENOCARCINOMA OF LARGE BOWEL Preetham Boddana. Richard Bright Unit, Southmead Hospital, Bristol, United Kingdom Introduction: Glomerular disease like crescentic glomerulonephritis may occur in systemic autoimmune diseases but occasionally, malignancies may coexist and are diagnosed at the same time as glomerular disease. We present a case of crescentic glomerulonephritis where in adenocarcinoma of large bowel was diagnosed at the same time. Case report: A healthy 73 year male was admitted to our renal unit after routine blood tests revealed him to be in acute renal impairment with serum creatinine measuring 350µmol/l. He had non-specific symptoms for several weeks before being admitted, mostly revolving around new onset of constipation. CT scan of abdomen done at his general hospital revealed some thickening of the terminal ileum. P-ANCA came back positive at1/160, MPO/PR3 equivocal. Renal biopsy subsequently performed showed focal necrotising crescentic glomerulonephritis. He was commenced on steroids and cyclophosamide. To examine the abnormal area of bowel picked up on CT scan, he went on to have a colonoscopy and a biopsy was taken. Caecal biopsy report confirmed Adenocarcinoma of signet ring cell type. Conclusion: A number of reports have suggested an association between malignancy and crescentic glomerulonephritis. Long term immunosuppression
A MYSTERIOUS CASE OF CHRONIC ITCHY Giovita A. Piccillo, Aurelio Pantò, Maurizio Nicolosi, Enrico G.M. Mondati, Riccardo Polosa, Luca Miele, Giovanni Gasbarrini. Department of Emergency Medicine, Cannizzaro Hospital, Catania, Italy Introduction: Ekbom syndrome is a psychiatric disorder, first described by Thibierge in 1894 and recognized as Delusional Parasitosis (DP) by Ekbom in 1938, in which the patients imagine the symptoms of parasitic infestation of the skin. They feel like bugs, worms, or mites that are biting, crawling, or burrowing into, under, or out of the skin. It may occur at any age but is more common in the elderly, particularly in females. It is classified in DSM IV as a non-schizophrenic delusions. Diagnosis is made excluding true infestations, contact dermatitis, allergies, alcohol/drug abuse. Therapy is based on antipsychotic agents, psychotherapy and psychoanalysis. Clinical Case: A 62 year-old man, no smoker and no drug and alcohol/abuser, affected with hypertension treated on enalapril, was admitted to our Dept for intense itchy, biting and rashes, due, on the basis of his opinion, to parasitosis involving also the eyes. He had visited many Dermatologists and never it had been demonstrated a dermatological pathology. He appeared pale, tachycardic and very anxious with skin completely involved by ulcerations due to scraping. Normal were his eyes, although he insistently complained the presence of parasites in that. BP 170/100 mmHg, HR 100 b/min, T 37 °C.
Oral Communications / European Journal of Internal Medicine 19S (2008), S1–S59
This case demonstrates a grave viral infection that is typical in situations of immunodeficiency and that should alert us to further study of pathologies associated with the immune system
TH-37 CLINICAL CASE OF CHRONIC DIARRHEA AND NON-HODGKIN’S LYMPHOMA Luís Andrade, Marco Fernandes, Ermelinda Gonçalves, Manuela Brochado. Hospital São Sebastião, Internal Medicine Department Introduction: The gastrointestinal tract is the predominant site of extranodal non-Hodgkin’s lymphomas. Primary NHLs of the GI tract are rare, accounting for only 1 to 4 percent of malignancies arising in the stomach, small intestine, or colon. In contrast, secondary GI involvement is relatively common, occurring in approximately 10 percent of patients with limited stage NHL lymphomas at the time of diagnosis, and up to 60 percent of those dying from advanced NHL. Despite their rarity, primary NHL lymphomas of the GI tract are important, since their management and prognosis are distinct from that of adenocarcinomas of the GI tract. %). The incidence is approximately 2.9/100.000 adults per year. In 40% of the situations they reveal extra-nodal involvement being the gastrointestinal tract one of the most frequent affected (75%). The management will consist of surgery and chemotherapy with survival in 5 years of 26% 73% and complete remission in 40% of the cases. Clinical case: A 42 year-old man with a Gastric Non-Hodgkin’s Lymphoma of B-cell origin, stage IIE-B diagnosed in October 2005 an submitted to a total gastrectomy and 4 cycles of QT with CHOP. In remission until October 2006, he initiated epigastric pain, weight loss, asthenia and diarrhea. Abdominal CAT scan showed a retroperitoneal adenopathy, upper gastrointestinal endoscopic was normal. Suspecting of non-Hodgkin lymphoma relapse was initiated a second line chemotherapy with ESHAP (2 cycles in December and January). The patient maintain diarrhea and he was asthenic, cachetic, desidrated with hypotension but normocardic, apiretic, pulmonary and cardiac auscultation normal, abdominal examination painless and without mass or organomegaly, moderate periphery oedema, without palpable peripherical adenopathy; Hb 7,2 g/dl (normocitic/normocromic), leucocyte 1900/ul with 1300/ul neutrophil and 500/ul lymphocite, platelet 113.000/ul; sodium 132, potassium 2,6 and magnesium 0,6 Mg mmol/l; Calcium 6,4 and phosphoru 1,9 mg/dl; total protein 2,7 and albumin 1.1 mg/dl; Fecal examination: bacteriologic and parasitologic negative Clostridium toxin difficile negative. Upper gastrointestinal endoscopy: jejunal erythema, oedema and erosion. Biopsy: enteric mucosa involvement with diffuse large B-cell non-Hodgkin lymphoma. The patient was in parentheric nutrition and one week later with correction of the analytic alteration and with better physical quality was programmed chemotherapy with ESAPH that carried through the 23/03. Three days later the patient initiated neutropenia and fever, medicated with Meropenem, Amikacin and Fluconazol but with gradual aggravation and die one week later. Conclusion: The authors present a clinical case of a sick person interned in a department of Internal Medicine.
can result in haematological malignancies as well as solid organ tumours. In our case both glomerular disease and large bowel malignancy were diagnosed more or less at the same time, raising possibility of association between ANCA positive crescentic glomerulonephritis and malignancy. Our case is also unique in being probably the first case wherein crescentic glomerulonephritis and adenocarcinoma of large bowel (signet ring cell type) has been reported. However there is need for analysis or trials looking into prevalence and association of ANCA in cancer patients
TH-39 A CASE OF EXTRAPULMONARY TUBERCULOSIS (EPT) WITH MULTIPLE BONE AND LYMPHONODAL INVOLVEMENT Alessia Rosato, Eleonora Pistella, Claudio Santini. U.O.C. Medicina Interna – Ospedale Vannini - Roma A 61 old year Indian, nun, in Italy since 40 years, was hospitalised for posterior thoracic pain and weight lost in the previous 3 months. She refers slowly resolving pneumonia 20 years ago. The temperature was 37.4°C. A painless 4 cm tender nodule was found in the left parietal area of the skull. A hard, fixed lymph node of 3 cm was palpable in the right supraclavear region. The white-cell count was 12.700/mm3, the ESR was 37 mm/hr, the C reactive protein was 3.29. Tuberculin skin test was strongly positive. Radiographs of the chest was normal. MRI scan of the thoracic spine showed a soft-tissue mass causing erosion of the anterior aspect of T4, extending to the prevertebral tissue. A total body CT scan showed multiple enlarged mediastinal and intraabdominal lymph nodes, up to 3 cm and 3 osteolytic lesions in T4, L4 and in the left parietal bone. The findings seemed suggestive for malignancy, lymphoma or multiple myeloma. Upper and lower GI endoscopy and mammography were normal. No monoclonal component was found. The excisional biopsy of the palpable supraclavear node revealed chronic granulomatous inflammation with epithelioid and giant cells, and necrotic material. A Ziehl–Neelsen stain and cultures for M. tuberculosis were negative. HIV test was negative. Four-drug antimycobacterial therapy was started. After two months she was afebrile, the thoracic pain decreased and the parietal nodule disappeared. EPT usually occurs in patients with evidence of active or previous pulmonary disease. In immunocompromised patients (primary HIV) EPT without evidence of pulmonary involvement can occur, often with impressive lymphadenopathy. In this setting, bone involvement can be multiple, rather than the characteristic picture of Pott’s disease. Our patient suggests that EPT without pulmonary involvement in immunocompetent patients represent an emergent disease and should be considered in differential diagnosis of diffuse lymphadenopathy or multiple destructive bone lesions.
TH-40 TH-38 A CASE OF CRESCENTIC GLOMERULONEPHRITIS AND ADENOCARCINOMA OF LARGE BOWEL Preetham Boddana. Richard Bright Unit, Southmead Hospital, Bristol, United Kingdom Introduction: Glomerular disease like crescentic glomerulonephritis may occur in systemic autoimmune diseases but occasionally, malignancies may coexist and are diagnosed at the same time as glomerular disease. We present a case of crescentic glomerulonephritis where in adenocarcinoma of large bowel was diagnosed at the same time. Case report: A healthy 73 year male was admitted to our renal unit after routine blood tests revealed him to be in acute renal impairment with serum creatinine measuring 350µmol/l. He had non-specific symptoms for several weeks before being admitted, mostly revolving around new onset of constipation. CT scan of abdomen done at his general hospital revealed some thickening of the terminal ileum. P-ANCA came back positive at1/160, MPO/PR3 equivocal. Renal biopsy subsequently performed showed focal necrotising crescentic glomerulonephritis. He was commenced on steroids and cyclophosamide. To examine the abnormal area of bowel picked up on CT scan, he went on to have a colonoscopy and a biopsy was taken. Caecal biopsy report confirmed Adenocarcinoma of signet ring cell type. Conclusion: A number of reports have suggested an association between malignancy and crescentic glomerulonephritis. Long term immunosuppression
A MYSTERIOUS CASE OF CHRONIC ITCHY Giovita A. Piccillo, Aurelio Pantò, Maurizio Nicolosi, Enrico G.M. Mondati, Riccardo Polosa, Luca Miele, Giovanni Gasbarrini. Department of Emergency Medicine, Cannizzaro Hospital, Catania, Italy Introduction: Ekbom syndrome is a psychiatric disorder, first described by Thibierge in 1894 and recognized as Delusional Parasitosis (DP) by Ekbom in 1938, in which the patients imagine the symptoms of parasitic infestation of the skin. They feel like bugs, worms, or mites that are biting, crawling, or burrowing into, under, or out of the skin. It may occur at any age but is more common in the elderly, particularly in females. It is classified in DSM IV as a non-schizophrenic delusions. Diagnosis is made excluding true infestations, contact dermatitis, allergies, alcohol/drug abuse. Therapy is based on antipsychotic agents, psychotherapy and psychoanalysis. Clinical Case: A 62 year-old man, no smoker and no drug and alcohol/abuser, affected with hypertension treated on enalapril, was admitted to our Dept for intense itchy, biting and rashes, due, on the basis of his opinion, to parasitosis involving also the eyes. He had visited many Dermatologists and never it had been demonstrated a dermatological pathology. He appeared pale, tachycardic and very anxious with skin completely involved by ulcerations due to scraping. Normal were his eyes, although he insistently complained the presence of parasites in that. BP 170/100 mmHg, HR 100 b/min, T 37 °C.