- Email: [email protected]
Gastric syphilis: an unusual endoscopic appearance
Atropine for colonoscopy: no benefit
procedure, causing parotid vasodilation and consequent transient enlargement. 2
To the Editor: Dr. Waxman and colleagues, in their study demonstrating no significant benefit from atropine for colonoscopy,! mention "there have been no prospectively designed trials to evaluate the usefulness of atropine during colonoscopy." They have overlooked a study by Ms. Saviage and myself, probably because it was published as an abstract. 2 We prospectively studied 108 patients undergoing colonoscopy. They were randomized to receive 1 mg of atropine subcutaneously or an identical-appearing injection of saline 5 min before the procedure. The patients and the endoscopist were blinded. Each patient received 0.07 mg of diazepam/kg intravenously for the procedure (not "0.07 mg" as indicated in the abstract-a typographical error). We evaluated the ease of colonoscopy from both the patient's and endoscopist's viewpoint and colonic motility and, like Dr. Waxman et al., demonstrated no significant benefit from pre-medication with atropine. We found no cardiac complications in either group.
Sandeep Nijhawan, MD R. R. Rai, MD Department of Gasuoenterology SMS Medical College Jaipur, India
REFERENCES 1. Blackford RW. Recurrent swelling of parotid and submaxillary gland following bronchoscopy. Ann Otol Rhinol Laryngol 1974;53:54-64. 2. Bonchek LI. Salivary gland enlargement during induction of anaesthesia. JAMA 1969;209:1716-8. 3. Slaughter RL, Boyce HW. Submaxillary gland swelling developing during peroral endoscopy. Gastroenterology 1969;57:838. 4. Shields HM, Soloway RD, Long WB, Weiss JB. Bilateral recurrent parotid swelling after endoscopy. Gastroenterology 1977;73:164-5. 5. Gardon MJ. Transient submandibular swelling following esophagoduodenoscopy. Am J Dig Dis 1976;21:507-8. 6. Slaughter RL. Parotid gland swelling developing during peroral endoscopy. Gastointest Endosc 1975;22:38-9.
Robert G. Norfleet, MD Kay Saviage, LPN Department of Gastroenterology Marshfield Clinic Marshfield, Wisconsin
Gastric syphilis: an unusual endoscopic appearance To the Editor:
REFERENCES 1. Waxman I, Mathews J, Gallagher J, et al. Limited benefit of atropine as pre-medication for colonoscopy. Gastrointest Endose 1991;37:329-31. 2. Norfleet RG, Saviage K: Atropine premedication for colonoscopy: a randomized double-blind study [Abstract]. Gastrointest Endosc. 1983;29:157.
Parotid swelling after upper gastrointestinal endoscopy To the Editor: We report a rare complication after upper gastrointestinal endoscopy. A 40-year-old woman underwent the procedure for suspected non-ulcer dyspepsia. The procedure was completed in 5 min although the patient strained and coughed during the initial part of the procedure. No medication was given to the patient before the procedure, and there was no past history of parotid swelling. Immediately after the procedure, the patient developed painful swelling of the right parotid gland, which was tender on palpation. The swelling subsided in 3 hours without specific medication. Such complications have been reported in the past following bronchoscopy,! endotracheal intubation for anesthesia,2 rigid esophagoscopy,3 and flexible upper gastrointestinal endoscopy.4 Submandibular5 and parotid4,6 salivary glands are involved. There are three proposed mechanisms. First, it may be because of retention of saliva resulting from blocking of ducts by thick secretions. 4 Second, coughing and straining during the procedure may lead to venous congestion of the parotid gland. Finally, swelling may arise as a result of intense parasympathetic stimulation during the 94
Dating back to the great pox pandemic of the late 15th century, syphilis has been recognized as an entity with protean manifestations. Although gastrointestinal manifestations may range from patchy proctitis to lesions resembling malignancy, the stomach is the most commonly involved site in gastrointestinal syphilis. 1 Beginning with the introduction of penicillin, the incidence of syphilis and reports of gastric involvement declined markedly. In the last 20 years, there have been only eight reports of biopsy-proven gastric syphilis in the English literature. 2-9 In the last decade, however, the number of reported cases of syphilis has risen steadily.lO We report a case of gastric syphilis characterized by an unusual endoscopic appearance. A previously healthy 26-year-old man was admitted to the hospital because of epigastric pain, nausea, and coffeeground emesis beginning 1 week before admission. The physical examination revealed no mucous membrane lesions in the oropharynx or urogenital area. There was no adenopathy. Abdominal examination showed only moderate epigastric tenderness, and the rectal examination was normal with heme-negative stool. Routine laboratory tests were normal, and his hematocrit was 44%. Esophagogastroduodenoscopy revealed a normally distensible stomach with a normal-appearing esophagus and duodenum. The stomach itself, however, contained more than 100 shallow ulcerations, ranging in size from a few millimeters to 1 em, which were concentrated most heavily in the antrum. They were notable for their brownish purplecolored bases and whitish exudate along their border (Fig. 1). There was no evidence of focal hemorrhage, and the intervening mucosa appeared to be normal. In addition, a solitary, deep, 5-cm ulcer was seen along the angulus. Biop~SrnillN~STI~LEND~C~Y
Figure 1. Gastroscopic appearance of secondary syphilis. View of the antrum showing superficial ulceration with brownish purple-colored base and surrounding white exudate. Figure 2. Warthin-Starry stain of a biopsy taken from a gastric lesion as seen in Figure 1. Note the presence of many spirochetes (arrows) (original magnification X1000).
sies taken from many of the shallow ulcerations as well as from the larger angulus ulcer revealed dense plasma cell infiltration of the lamina propria. Acute inflammation and focal ulceration showing coagulative necrosis and proliferation of blood vessels lined by prominent endothelial cells . were also seen. The Warthin-Starry stain showed many spirochetes (Fig. 2). Because of the above findings, further history and serological tests were obtained. The patient was single and denied recent sexual contacts. He admitted to engaging in sexual relations with a prostitute several years earlier. He was, however, unable to recall having had a penile ulcer, lymphadenopathy, or skin rash at any time. Human immunodeficiency virus antibody testing was negative. The serum VDRL was positive at a titer of 1:128, and the corresponding treponemal immunofluorescence studies were positive. On the basis of this information, a diagnosis of severe ulcerative syphilitic gastritis was made. The patient's high titer VDRL was felt to be most consistent with early secondary syphilis. The patient ultimately received three weekly intramuscular injections of 2.4 million units of benzathine penicillin. In addition, he took cimetidine (800 mg/day) as well as a 7day course of doxycycline (100 mg twice daily). Within 4 days of beginning appropriate therapy, his symptoms had VOLUME 38, NO.1, 1992
completely resolved. Repeat esophagogastroduodenoscopy performed 3 weeks after he began taking penicillin revealed almost complete disappearance of the multiple shallow ulcerations, as well as evidence of healing in the large angulus ulcer. Although repeat biopsies again showed a plasma cell infiltrate, the Warthin-Starry stain no longer demonstrated spirochetes. Through the refinement of direct gastric visualization and biopsy techniques, endoscopy has allowed the diagnosis of gastric syphilis to be made more reliably and much earlier in the course of the disease. In fact, a variety of endoscopic appearances have been described. In 1948, Patterson and Rouse described the gastroscopic appearance of luetic lesions in late syphilis. 1 Of the 14 cases they presented, 8 had an ulcerating or ulceronodular appearance, 3 had nodular or gummatous tumor without ulceration, and the remainder had an infiltrative or "leather bottle" appearance. They commented that many of these ulcers had a violaceous, slightly brownish, or purplish red hue along their margins. They speculated that this discoloration resulted from a fibrosing and obliterating panvasculitis of the submucosa. Moreover, they felt that such lesions were distinct in appearance from the normal pink-colored mucosa surrounding a peptic ulcer or the fiery red, highly vascular margins of an ulcerating malignancy. Of the more recent cases of gastric syphilis appearing in the literature, most have reported patients who had early syphilis. Interestingly, in several reports including ours, the patients described did not have extragastric manifestations of this disease. 2 ,5,6 The endoscopic descriptions are diverse. The most commonly reported findings are multiple ulcerations and superficial erosions occurring mainly in the antrum. 3 ,5, 7,9,11 Such lesions may have serpiginous margins and can be quite large. 12, 13 The mucosa is frequently friable and erythematous. Gastric distensibility, primarily in the antrum, is commonly decreased, and the rugal folds may be enlarged. 13,14 Mass-like nodular lesions have also been described and sometimes have a dark red coloration. 4 ,12 Biopsy specimens typically demonstrate mucosal infiltration by plasma cells and lymphocytes along with endothelial cell proliferation in small arterioles. 2 ,4-7,12 When the diagnosis of gastric syphilis has been established, antiluetic treatment with benzathine penicillin is highly efficacious. Four reports have described follow-up endoscopy findings within 1 month after treatment with penicillin. 2,5,6,12 In each case, dramatic resolution of the mucosal abnormalities was noted. In fact, Beckman and Schuman documented the disappearance of superficial ulcerations and red-brown nodularity in one patient just 4 days after beginning treatment. 12 The brownish purple discoloration of ulcer margins, felt by Patterson and Rouse 1 to be so characteristic of late gastric syphilis, bears some resemblance to the red-brown mucosal nodularity noted by Beckman and Schuman 12 in early secondary syphilis, as well as to the ulcer base discoloration described in this report. Although there may be a common pathological mechanism to account for all of these changes, a precise explanation for this rapidly reversible finding has not been found. It is possible that the coagulative necrosis seen in our patient was somewhat responsible for this appearance. Except for the disappearance of spirochetes, how95
ever, biopsies taken during our patient's second endoscopy were histologically unchanged when compared with those from the first. Thus, it appears likely that the unusual coloration that we describe in this report is attributable to a high number of Treponema pallidum in these lesions. The disappearance of organisms may therefore contribute to the rapid resolution of the abnormal endoscopic findings seen in this disease. Matthew B. Smith, MD Thomas N. Levin, MD Department of Medicine University of Chicago Medical Center Chicago, Illinois
REFERENCES 1. Patterson CO, Rouse MO. Description of gastroscopic appearance of leutic gastric lesions in late acquired syphilis. Gastroenterology 1948;10:474-85. 2. Sachar DB, Klein RS, Swerdlow F, et al. Erosive syphilitic gastritis: darkfield and immunofluorescent diagnosis from biopsy specimens. Ann Intern Med 1974;80:512-5. 3. Butz WC, Watts JC, Rosales-Quintana S, Hicklin MD. Erosive gastritis as a manifestation of secondary syphilis. Am J Clin Pathol 1975;63:895-900. 4. DeLuca RF, Morton R, Kafka EC, Raskin JB. Early luetic gastritis presenting as an antral mass. Gastrointest Endosc 1975;22:95. 5. Reisman TN, Leverett L, Hudson JR, Kaiser MH. Syphilitic gastropathy. Dig Dis 1975;20:588-93. 6. Morin ME, Tan A. Diffuse enlargement of gastric folds as a manifestation of secondary syphilis. Am J Gastroenterol 1980;74:170-2. 7. Besses C, Sans-Sabrafen J, Badia X, Rodriquez-Mendez F, Salord JC, Armengol JR. Ulceroinfiltrative syphilitic gastropathy: silver stain diagnosis from biopsy specimen. Am J GastroenteroI1987;82:773-4. 8. Bottari M, Melina D, Napoli P, Pallio S, Puglisi A, Villari D. Gastric lesions in secondary syphilis. Gastrointest Endosc 1988;34:437-9. 9. Parker CH, Garner DC, Weiserbs D, Barritt AS. Gastric syphilis in an HIV negative patient. Am J Gastroenterol 1990;85:1244. 10. Summary of notifiable diseases, United States 1989. MMWR 1990;38:39-58. 11. Schwartz IR. Gastroscopic observations in secondary syphilis Gastroenterology 1948;10:227-30. 12. Beckman JW, Schuman BM. Antral gastritis and ulceration in a patient with secondary syphilis. Gastrointest Endosc 1986;32:355-6. 13. Mitchell RM, Bralow SP. Acute erosive gastritis due to early syphilis. Ann Intern Med 1964;61:933-8. 14. Anai H, Okada Y, Okubo K, et al. Gastric syphilis simulating linitis plastica type of gastric cancer. Gastrointest Endosc 1990;36:624-6.
without skin lesions can also occur. 4 Barium studies in such patients have been normaJ.4 A 31-year-old Haitian woman was hospitalized with epigastric pain, vomiting, and 20-lb weight loss over a 2-month period. She had been treated with ranitidine by an outside physician for presumed peptic ulcer disease. The patient had been living in the United States for 4 years and denied both intravenous drug abuse and the receipt of transfused blood products. Physical examination revealed a temperature of 101°F, gastric tenderness, and guaiac-positive stool. The skin was of normal appearance. The white blood cell count was 1400/mm3, and the hemoglobin was 9.1 gldl. Human immunodeficiency virus serologies were positive. The absolute CD4 count was 11Ill. Upper gastrointestinal barium studies demonstrated poor gastric distensibility with markedly thickened gastric folds-findings consistent with linitis plastica. The pyloric channel appeared elongated. Upper gastrointestinal endoscopy found the esophagus to be normal, but the stomach was poorly distensible with a diffuse, nodular appearance. The mucosa of the cardia, fundus, and body was friable and erythematous. Although the antrum appeared normal, the pyloric channel was noted to be involved with an infiltrative process. The duodenum was normal. Multiple biopsies were taken that demonstrated Kaposi's sarcoma. The patient was begun on intravenous chemotherapy with vincristine along with chlorpromazine for her unremitting vomiting and morphine sulfate for pain. Initially, the patient's oral intake and sense of well-being improved. However, over the next several months, intractable vomiting necessitated parenteral nutrition. With continued leukopenia, fungemia supervened and the patient died despite intravenous therapy with amphotericin B. This case is to our knowledge, the first such report that illustrates that gastric Kaposi's sarcoma can have the radiographic appearance of linitis plastica. Because such symptomatic, gastric involvement can occur in the absence of cutaneous lesions and because the response rate of symptomatic gastrointestinal Kaposi's sarcoma to chemotherapy is similar to that of cutaneous Kaposi's sarcoma (60% remission),5 it would appear that upper gastrointestinal endoscopy with biopsy of suspicious lesions is indicated in symptomatic human immunodeficiency virus-seropositive patients whether or not there are skin lesions. Joseph S. Cervia, MD Division of Infectious Disease Nassau County Medical Center East Meadow, New York
REFERENCES
Gastric Kaposi's sarcoma without skin lesions presenting as linitis plastica To the Editor: Gastrointestinal Kaposi's sarcoma lesions have been reported in up to 40% of patients with AIDS but are usually asymptomatic, rarely resulting in bleeding or obstruction.! Although early studies have suggested that gastrointestinal Kaposi's sarcoma is more likely to be present if there is extensive cutaneous disease,2,3 more recent evidence indicates that upper gastrointestinal involvement in patients 96
1. Friedman S. Gastrointestinal and hepato-bilary neoplasms in AIDS. Gastroenterol Clin North Am 1988;17:465-86. 2. Saltz R, Kurtz R, Lightdale C, et al. Kaposi's sarcoma: gastrointestinal involvement and correlation with skin findings and immunologic function. Dig Dis Sci 1984;29:817-23. 3. Friedman S, Wright T, Altman D. Gastrointestinal Kaposi's sarcoma in patients with acquired immunodeficiency syndrome. Gastroenterology 1985;89:102-8. 4. Barrison I, Foster S, Harris J, Pinching A, Walker J. Upper gastrointestinal Kaposi's sarcoma in patients positive for HIV antibody without cutaneous disease. Br Med J 1988;296:92-3. 5. Laine L, Amerian J, Rarick M, Harb M, Gill P. The response of symptomatic gastrointestinal Kaposi's sarcoma to chemotherapy: a prospective evaluation using an endoscopic method of disease quantification. Am J Gastroenterol 1990;85:959-61. ~SrnmN~STI~LEND~C@Y
procedure, causing parotid vasodilation and consequent transient enlargement. 2
To the Editor: Dr. Waxman and colleagues, in their study demonstrating no significant benefit from atropine for colonoscopy,! mention "there have been no prospectively designed trials to evaluate the usefulness of atropine during colonoscopy." They have overlooked a study by Ms. Saviage and myself, probably because it was published as an abstract. 2 We prospectively studied 108 patients undergoing colonoscopy. They were randomized to receive 1 mg of atropine subcutaneously or an identical-appearing injection of saline 5 min before the procedure. The patients and the endoscopist were blinded. Each patient received 0.07 mg of diazepam/kg intravenously for the procedure (not "0.07 mg" as indicated in the abstract-a typographical error). We evaluated the ease of colonoscopy from both the patient's and endoscopist's viewpoint and colonic motility and, like Dr. Waxman et al., demonstrated no significant benefit from pre-medication with atropine. We found no cardiac complications in either group.
Sandeep Nijhawan, MD R. R. Rai, MD Department of Gasuoenterology SMS Medical College Jaipur, India
REFERENCES 1. Blackford RW. Recurrent swelling of parotid and submaxillary gland following bronchoscopy. Ann Otol Rhinol Laryngol 1974;53:54-64. 2. Bonchek LI. Salivary gland enlargement during induction of anaesthesia. JAMA 1969;209:1716-8. 3. Slaughter RL, Boyce HW. Submaxillary gland swelling developing during peroral endoscopy. Gastroenterology 1969;57:838. 4. Shields HM, Soloway RD, Long WB, Weiss JB. Bilateral recurrent parotid swelling after endoscopy. Gastroenterology 1977;73:164-5. 5. Gardon MJ. Transient submandibular swelling following esophagoduodenoscopy. Am J Dig Dis 1976;21:507-8. 6. Slaughter RL. Parotid gland swelling developing during peroral endoscopy. Gastointest Endosc 1975;22:38-9.
Robert G. Norfleet, MD Kay Saviage, LPN Department of Gastroenterology Marshfield Clinic Marshfield, Wisconsin
Gastric syphilis: an unusual endoscopic appearance To the Editor:
REFERENCES 1. Waxman I, Mathews J, Gallagher J, et al. Limited benefit of atropine as pre-medication for colonoscopy. Gastrointest Endose 1991;37:329-31. 2. Norfleet RG, Saviage K: Atropine premedication for colonoscopy: a randomized double-blind study [Abstract]. Gastrointest Endosc. 1983;29:157.
Parotid swelling after upper gastrointestinal endoscopy To the Editor: We report a rare complication after upper gastrointestinal endoscopy. A 40-year-old woman underwent the procedure for suspected non-ulcer dyspepsia. The procedure was completed in 5 min although the patient strained and coughed during the initial part of the procedure. No medication was given to the patient before the procedure, and there was no past history of parotid swelling. Immediately after the procedure, the patient developed painful swelling of the right parotid gland, which was tender on palpation. The swelling subsided in 3 hours without specific medication. Such complications have been reported in the past following bronchoscopy,! endotracheal intubation for anesthesia,2 rigid esophagoscopy,3 and flexible upper gastrointestinal endoscopy.4 Submandibular5 and parotid4,6 salivary glands are involved. There are three proposed mechanisms. First, it may be because of retention of saliva resulting from blocking of ducts by thick secretions. 4 Second, coughing and straining during the procedure may lead to venous congestion of the parotid gland. Finally, swelling may arise as a result of intense parasympathetic stimulation during the 94
Dating back to the great pox pandemic of the late 15th century, syphilis has been recognized as an entity with protean manifestations. Although gastrointestinal manifestations may range from patchy proctitis to lesions resembling malignancy, the stomach is the most commonly involved site in gastrointestinal syphilis. 1 Beginning with the introduction of penicillin, the incidence of syphilis and reports of gastric involvement declined markedly. In the last 20 years, there have been only eight reports of biopsy-proven gastric syphilis in the English literature. 2-9 In the last decade, however, the number of reported cases of syphilis has risen steadily.lO We report a case of gastric syphilis characterized by an unusual endoscopic appearance. A previously healthy 26-year-old man was admitted to the hospital because of epigastric pain, nausea, and coffeeground emesis beginning 1 week before admission. The physical examination revealed no mucous membrane lesions in the oropharynx or urogenital area. There was no adenopathy. Abdominal examination showed only moderate epigastric tenderness, and the rectal examination was normal with heme-negative stool. Routine laboratory tests were normal, and his hematocrit was 44%. Esophagogastroduodenoscopy revealed a normally distensible stomach with a normal-appearing esophagus and duodenum. The stomach itself, however, contained more than 100 shallow ulcerations, ranging in size from a few millimeters to 1 em, which were concentrated most heavily in the antrum. They were notable for their brownish purplecolored bases and whitish exudate along their border (Fig. 1). There was no evidence of focal hemorrhage, and the intervening mucosa appeared to be normal. In addition, a solitary, deep, 5-cm ulcer was seen along the angulus. Biop~SrnillN~STI~LEND~C~Y
Figure 1. Gastroscopic appearance of secondary syphilis. View of the antrum showing superficial ulceration with brownish purple-colored base and surrounding white exudate. Figure 2. Warthin-Starry stain of a biopsy taken from a gastric lesion as seen in Figure 1. Note the presence of many spirochetes (arrows) (original magnification X1000).
sies taken from many of the shallow ulcerations as well as from the larger angulus ulcer revealed dense plasma cell infiltration of the lamina propria. Acute inflammation and focal ulceration showing coagulative necrosis and proliferation of blood vessels lined by prominent endothelial cells . were also seen. The Warthin-Starry stain showed many spirochetes (Fig. 2). Because of the above findings, further history and serological tests were obtained. The patient was single and denied recent sexual contacts. He admitted to engaging in sexual relations with a prostitute several years earlier. He was, however, unable to recall having had a penile ulcer, lymphadenopathy, or skin rash at any time. Human immunodeficiency virus antibody testing was negative. The serum VDRL was positive at a titer of 1:128, and the corresponding treponemal immunofluorescence studies were positive. On the basis of this information, a diagnosis of severe ulcerative syphilitic gastritis was made. The patient's high titer VDRL was felt to be most consistent with early secondary syphilis. The patient ultimately received three weekly intramuscular injections of 2.4 million units of benzathine penicillin. In addition, he took cimetidine (800 mg/day) as well as a 7day course of doxycycline (100 mg twice daily). Within 4 days of beginning appropriate therapy, his symptoms had VOLUME 38, NO.1, 1992
completely resolved. Repeat esophagogastroduodenoscopy performed 3 weeks after he began taking penicillin revealed almost complete disappearance of the multiple shallow ulcerations, as well as evidence of healing in the large angulus ulcer. Although repeat biopsies again showed a plasma cell infiltrate, the Warthin-Starry stain no longer demonstrated spirochetes. Through the refinement of direct gastric visualization and biopsy techniques, endoscopy has allowed the diagnosis of gastric syphilis to be made more reliably and much earlier in the course of the disease. In fact, a variety of endoscopic appearances have been described. In 1948, Patterson and Rouse described the gastroscopic appearance of luetic lesions in late syphilis. 1 Of the 14 cases they presented, 8 had an ulcerating or ulceronodular appearance, 3 had nodular or gummatous tumor without ulceration, and the remainder had an infiltrative or "leather bottle" appearance. They commented that many of these ulcers had a violaceous, slightly brownish, or purplish red hue along their margins. They speculated that this discoloration resulted from a fibrosing and obliterating panvasculitis of the submucosa. Moreover, they felt that such lesions were distinct in appearance from the normal pink-colored mucosa surrounding a peptic ulcer or the fiery red, highly vascular margins of an ulcerating malignancy. Of the more recent cases of gastric syphilis appearing in the literature, most have reported patients who had early syphilis. Interestingly, in several reports including ours, the patients described did not have extragastric manifestations of this disease. 2 ,5,6 The endoscopic descriptions are diverse. The most commonly reported findings are multiple ulcerations and superficial erosions occurring mainly in the antrum. 3 ,5, 7,9,11 Such lesions may have serpiginous margins and can be quite large. 12, 13 The mucosa is frequently friable and erythematous. Gastric distensibility, primarily in the antrum, is commonly decreased, and the rugal folds may be enlarged. 13,14 Mass-like nodular lesions have also been described and sometimes have a dark red coloration. 4 ,12 Biopsy specimens typically demonstrate mucosal infiltration by plasma cells and lymphocytes along with endothelial cell proliferation in small arterioles. 2 ,4-7,12 When the diagnosis of gastric syphilis has been established, antiluetic treatment with benzathine penicillin is highly efficacious. Four reports have described follow-up endoscopy findings within 1 month after treatment with penicillin. 2,5,6,12 In each case, dramatic resolution of the mucosal abnormalities was noted. In fact, Beckman and Schuman documented the disappearance of superficial ulcerations and red-brown nodularity in one patient just 4 days after beginning treatment. 12 The brownish purple discoloration of ulcer margins, felt by Patterson and Rouse 1 to be so characteristic of late gastric syphilis, bears some resemblance to the red-brown mucosal nodularity noted by Beckman and Schuman 12 in early secondary syphilis, as well as to the ulcer base discoloration described in this report. Although there may be a common pathological mechanism to account for all of these changes, a precise explanation for this rapidly reversible finding has not been found. It is possible that the coagulative necrosis seen in our patient was somewhat responsible for this appearance. Except for the disappearance of spirochetes, how95
ever, biopsies taken during our patient's second endoscopy were histologically unchanged when compared with those from the first. Thus, it appears likely that the unusual coloration that we describe in this report is attributable to a high number of Treponema pallidum in these lesions. The disappearance of organisms may therefore contribute to the rapid resolution of the abnormal endoscopic findings seen in this disease. Matthew B. Smith, MD Thomas N. Levin, MD Department of Medicine University of Chicago Medical Center Chicago, Illinois
REFERENCES 1. Patterson CO, Rouse MO. Description of gastroscopic appearance of leutic gastric lesions in late acquired syphilis. Gastroenterology 1948;10:474-85. 2. Sachar DB, Klein RS, Swerdlow F, et al. Erosive syphilitic gastritis: darkfield and immunofluorescent diagnosis from biopsy specimens. Ann Intern Med 1974;80:512-5. 3. Butz WC, Watts JC, Rosales-Quintana S, Hicklin MD. Erosive gastritis as a manifestation of secondary syphilis. Am J Clin Pathol 1975;63:895-900. 4. DeLuca RF, Morton R, Kafka EC, Raskin JB. Early luetic gastritis presenting as an antral mass. Gastrointest Endosc 1975;22:95. 5. Reisman TN, Leverett L, Hudson JR, Kaiser MH. Syphilitic gastropathy. Dig Dis 1975;20:588-93. 6. Morin ME, Tan A. Diffuse enlargement of gastric folds as a manifestation of secondary syphilis. Am J Gastroenterol 1980;74:170-2. 7. Besses C, Sans-Sabrafen J, Badia X, Rodriquez-Mendez F, Salord JC, Armengol JR. Ulceroinfiltrative syphilitic gastropathy: silver stain diagnosis from biopsy specimen. Am J GastroenteroI1987;82:773-4. 8. Bottari M, Melina D, Napoli P, Pallio S, Puglisi A, Villari D. Gastric lesions in secondary syphilis. Gastrointest Endosc 1988;34:437-9. 9. Parker CH, Garner DC, Weiserbs D, Barritt AS. Gastric syphilis in an HIV negative patient. Am J Gastroenterol 1990;85:1244. 10. Summary of notifiable diseases, United States 1989. MMWR 1990;38:39-58. 11. Schwartz IR. Gastroscopic observations in secondary syphilis Gastroenterology 1948;10:227-30. 12. Beckman JW, Schuman BM. Antral gastritis and ulceration in a patient with secondary syphilis. Gastrointest Endosc 1986;32:355-6. 13. Mitchell RM, Bralow SP. Acute erosive gastritis due to early syphilis. Ann Intern Med 1964;61:933-8. 14. Anai H, Okada Y, Okubo K, et al. Gastric syphilis simulating linitis plastica type of gastric cancer. Gastrointest Endosc 1990;36:624-6.
without skin lesions can also occur. 4 Barium studies in such patients have been normaJ.4 A 31-year-old Haitian woman was hospitalized with epigastric pain, vomiting, and 20-lb weight loss over a 2-month period. She had been treated with ranitidine by an outside physician for presumed peptic ulcer disease. The patient had been living in the United States for 4 years and denied both intravenous drug abuse and the receipt of transfused blood products. Physical examination revealed a temperature of 101°F, gastric tenderness, and guaiac-positive stool. The skin was of normal appearance. The white blood cell count was 1400/mm3, and the hemoglobin was 9.1 gldl. Human immunodeficiency virus serologies were positive. The absolute CD4 count was 11Ill. Upper gastrointestinal barium studies demonstrated poor gastric distensibility with markedly thickened gastric folds-findings consistent with linitis plastica. The pyloric channel appeared elongated. Upper gastrointestinal endoscopy found the esophagus to be normal, but the stomach was poorly distensible with a diffuse, nodular appearance. The mucosa of the cardia, fundus, and body was friable and erythematous. Although the antrum appeared normal, the pyloric channel was noted to be involved with an infiltrative process. The duodenum was normal. Multiple biopsies were taken that demonstrated Kaposi's sarcoma. The patient was begun on intravenous chemotherapy with vincristine along with chlorpromazine for her unremitting vomiting and morphine sulfate for pain. Initially, the patient's oral intake and sense of well-being improved. However, over the next several months, intractable vomiting necessitated parenteral nutrition. With continued leukopenia, fungemia supervened and the patient died despite intravenous therapy with amphotericin B. This case is to our knowledge, the first such report that illustrates that gastric Kaposi's sarcoma can have the radiographic appearance of linitis plastica. Because such symptomatic, gastric involvement can occur in the absence of cutaneous lesions and because the response rate of symptomatic gastrointestinal Kaposi's sarcoma to chemotherapy is similar to that of cutaneous Kaposi's sarcoma (60% remission),5 it would appear that upper gastrointestinal endoscopy with biopsy of suspicious lesions is indicated in symptomatic human immunodeficiency virus-seropositive patients whether or not there are skin lesions. Joseph S. Cervia, MD Division of Infectious Disease Nassau County Medical Center East Meadow, New York
REFERENCES
Gastric Kaposi's sarcoma without skin lesions presenting as linitis plastica To the Editor: Gastrointestinal Kaposi's sarcoma lesions have been reported in up to 40% of patients with AIDS but are usually asymptomatic, rarely resulting in bleeding or obstruction.! Although early studies have suggested that gastrointestinal Kaposi's sarcoma is more likely to be present if there is extensive cutaneous disease,2,3 more recent evidence indicates that upper gastrointestinal involvement in patients 96
1. Friedman S. Gastrointestinal and hepato-bilary neoplasms in AIDS. Gastroenterol Clin North Am 1988;17:465-86. 2. Saltz R, Kurtz R, Lightdale C, et al. Kaposi's sarcoma: gastrointestinal involvement and correlation with skin findings and immunologic function. Dig Dis Sci 1984;29:817-23. 3. Friedman S, Wright T, Altman D. Gastrointestinal Kaposi's sarcoma in patients with acquired immunodeficiency syndrome. Gastroenterology 1985;89:102-8. 4. Barrison I, Foster S, Harris J, Pinching A, Walker J. Upper gastrointestinal Kaposi's sarcoma in patients positive for HIV antibody without cutaneous disease. Br Med J 1988;296:92-3. 5. Laine L, Amerian J, Rarick M, Harb M, Gill P. The response of symptomatic gastrointestinal Kaposi's sarcoma to chemotherapy: a prospective evaluation using an endoscopic method of disease quantification. Am J Gastroenterol 1990;85:959-61. ~SrnmN~STI~LEND~C@Y