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Image of the Month
Image of the Month David M. Warshauer, Section Editor
Question: A 21-year-old man, previously in good health, presented with watery diarrhea; dysphagia and oral ulcers followed. Stool cultures were negative for bacteria other than normal flora. He was treated with bismuth, which did not alter his clinical course. Panendoscopy and colonoscopy were performed. The endoscopies revealed superficial ulcerations covered by a white pseudomembrane in the esophagus (Figure A). The scattered colonic ulcers were tiny and shallow, surrounded by erythematous and swelling mucosa (Figure B). Mucosa of the gastric corpus, antrum, duodenum, cecum, and terminal ileum was normal in appearance. The biopsy specimens of colonic ulcers showed acute and chronic mucosal inflammation without granulomas. In addition, ulcers of the penis and scrotum occurred 2 days after endoscopy examination (Figure C). Petechiae on palms of both hands also developed (Figure D). No previous drug exposure history was noted. On physical examination, he was found to have ulcerations on the tongue, palate, and buccal mucosa (Figure E). Multiple shallow ulcerations were also seen on his penis and scrotum. A few painful bullae on his feet were also found. Laboratory studies revealed a white blood cell count of
11,700/L, hemoglobin of 13.9 g/dL, platelets of 224/mm3, erythrocyte sedimentation rate of 43 mm/h, and C-reactive protein of 4.72 mg/dL. The stools were Hemoccult positive. What is the most likely diagnosis? Look on page 775 for the answer and see the Gastroenterology website (http://www.gastrojournal.org) for more information on submitting your favorite image to Image of the Month. PENG-JEN CHEN, MD RONG-YAUN SHYU, MD, PhD YOU-CHEN CHAO, MD Division of Gastroenterology Department of Internal Medicine Tri-Service General Hospital National Defense Medical Center Taipei, Taiwan © 2005 by the American Gastroenterological Association
0016-5085/05/$30.00 doi:10.1053/j.gastro.2005.05.039 GASTROENTEROLOGY 2005;129:407
August 2005
IMAGE OF THE MONTH
4. Baxter NN, Tepper JE, Durham SB, Rothenberger DA, Virnig BA. Increased risk of rectal cancer after prostate radiation: a population-based study. Gastroenterology 2005;128:819 – 824. 5. Neugut AI, Ahsan H, Robinson E, Ennis RD. Bladder carcinoma and other second malignancies after radiotherapy for prostate carcinoma. Cancer 1997;79:1600 –1604.
775
6. Pickles T, Phillips N. The risk of second malignancy in men with prostate cancer treated with or without radiation in British Columbia, 1984 –2000. Radiother Oncol 2002;65:145– 151. doi:10.1053/j.gastro.2005.06.046
Answer to the Image of the Month Question (page 407): Behçet’s Disease The skin lesions and oral and genital ulcers fulfilled the diagnosis of Behçet’s disease. He received glucocorticoid pulse therapy followed by oral prednisolone. His clinical symptoms, such as oral ulcers, dysphagia, and diarrhea, improved dramatically while taking the steroid. Manifestations of Behçet’s disease include oral and genital ulcerations, skin lesions, uveitis, arthritis, thrombophlebitis, and gastrointestinal, central nervous system, and cardiovascular involvement. Vascular injuries, hyperfunction of neutrophils, and autoimmune responses are characteristic of Behçet’s disease.1 Gastrointestinal involvement in Behçet’s disease may affect all areas from the lips to the anus.2 The ulcers are most commonly found in the terminal ileum and the cecum (75% of patients) and less frequently in the colon. Genital ulcers usually occur on the scrotum and penis in men and on the vulva in women.3 The treatments used for inflammatory bowel disease are also useful for the gastrointestinal lesions of Behçet’s disease. Sulfasalazine and corticosteroids are the principal drugs.3 The dose of corticosteroids depends on the severity of the lesions. Bowel rest is obligatory in patients with an acute abdomen and bleeding. Surgery is considered for patients with bowel perforation and persistent bleeding.4 References 1. Ehrlich GE. Vasculitis in Behçet’s disease. Int Rev Immunol 1997;14:81– 88. 2. Plotkin GR. Miscellaneous clinical manifestations, part II: gastrointestinal, hepatic, splenic, pancreatic, genitourinary, and dermatologic features. In: Plotkin GR, O’Duffy J D, eds. Behçet’s disease: a contemporary synopsis. Mount Kisco, New York: Futura Publishing, 1988:239 –279. 3. Kaklamani VG, Variopoulos G, Kaklamanis PG. Behçet’s disease. Semin Arthritis Rheum 1998;27:197–217. 4. Lee KS, Kim SJ, Lee BC, Yoon DS, Lee WJ, Chi HS. Surgical treatment of intestinal Behçet’s disease. Yonsei Med J 1997;38:455– 460. For submission instructions, please see the Gastroenterology website (http://www.gastrojournal.org).
Correction Shimizu K, Kobayashi M, Tahara J, Shiratori K. Cytokines and peroxisome proliferator-activated receptor ␥ ligand regulate phagocytosis by pancreatic stellate cells. Gastroenterology 2005;128:2105–2118.
The affiliation in the above article should have appeared as follows: *Departments of Gastroenterology and ‡Pathology, Tokyo Women’s Medical University, School of Medicine, Tokyo, Japan
Question: A 21-year-old man, previously in good health, presented with watery diarrhea; dysphagia and oral ulcers followed. Stool cultures were negative for bacteria other than normal flora. He was treated with bismuth, which did not alter his clinical course. Panendoscopy and colonoscopy were performed. The endoscopies revealed superficial ulcerations covered by a white pseudomembrane in the esophagus (Figure A). The scattered colonic ulcers were tiny and shallow, surrounded by erythematous and swelling mucosa (Figure B). Mucosa of the gastric corpus, antrum, duodenum, cecum, and terminal ileum was normal in appearance. The biopsy specimens of colonic ulcers showed acute and chronic mucosal inflammation without granulomas. In addition, ulcers of the penis and scrotum occurred 2 days after endoscopy examination (Figure C). Petechiae on palms of both hands also developed (Figure D). No previous drug exposure history was noted. On physical examination, he was found to have ulcerations on the tongue, palate, and buccal mucosa (Figure E). Multiple shallow ulcerations were also seen on his penis and scrotum. A few painful bullae on his feet were also found. Laboratory studies revealed a white blood cell count of
11,700/L, hemoglobin of 13.9 g/dL, platelets of 224/mm3, erythrocyte sedimentation rate of 43 mm/h, and C-reactive protein of 4.72 mg/dL. The stools were Hemoccult positive. What is the most likely diagnosis? Look on page 775 for the answer and see the Gastroenterology website (http://www.gastrojournal.org) for more information on submitting your favorite image to Image of the Month. PENG-JEN CHEN, MD RONG-YAUN SHYU, MD, PhD YOU-CHEN CHAO, MD Division of Gastroenterology Department of Internal Medicine Tri-Service General Hospital National Defense Medical Center Taipei, Taiwan © 2005 by the American Gastroenterological Association
0016-5085/05/$30.00 doi:10.1053/j.gastro.2005.05.039 GASTROENTEROLOGY 2005;129:407
August 2005
IMAGE OF THE MONTH
4. Baxter NN, Tepper JE, Durham SB, Rothenberger DA, Virnig BA. Increased risk of rectal cancer after prostate radiation: a population-based study. Gastroenterology 2005;128:819 – 824. 5. Neugut AI, Ahsan H, Robinson E, Ennis RD. Bladder carcinoma and other second malignancies after radiotherapy for prostate carcinoma. Cancer 1997;79:1600 –1604.
775
6. Pickles T, Phillips N. The risk of second malignancy in men with prostate cancer treated with or without radiation in British Columbia, 1984 –2000. Radiother Oncol 2002;65:145– 151. doi:10.1053/j.gastro.2005.06.046
Answer to the Image of the Month Question (page 407): Behçet’s Disease The skin lesions and oral and genital ulcers fulfilled the diagnosis of Behçet’s disease. He received glucocorticoid pulse therapy followed by oral prednisolone. His clinical symptoms, such as oral ulcers, dysphagia, and diarrhea, improved dramatically while taking the steroid. Manifestations of Behçet’s disease include oral and genital ulcerations, skin lesions, uveitis, arthritis, thrombophlebitis, and gastrointestinal, central nervous system, and cardiovascular involvement. Vascular injuries, hyperfunction of neutrophils, and autoimmune responses are characteristic of Behçet’s disease.1 Gastrointestinal involvement in Behçet’s disease may affect all areas from the lips to the anus.2 The ulcers are most commonly found in the terminal ileum and the cecum (75% of patients) and less frequently in the colon. Genital ulcers usually occur on the scrotum and penis in men and on the vulva in women.3 The treatments used for inflammatory bowel disease are also useful for the gastrointestinal lesions of Behçet’s disease. Sulfasalazine and corticosteroids are the principal drugs.3 The dose of corticosteroids depends on the severity of the lesions. Bowel rest is obligatory in patients with an acute abdomen and bleeding. Surgery is considered for patients with bowel perforation and persistent bleeding.4 References 1. Ehrlich GE. Vasculitis in Behçet’s disease. Int Rev Immunol 1997;14:81– 88. 2. Plotkin GR. Miscellaneous clinical manifestations, part II: gastrointestinal, hepatic, splenic, pancreatic, genitourinary, and dermatologic features. In: Plotkin GR, O’Duffy J D, eds. Behçet’s disease: a contemporary synopsis. Mount Kisco, New York: Futura Publishing, 1988:239 –279. 3. Kaklamani VG, Variopoulos G, Kaklamanis PG. Behçet’s disease. Semin Arthritis Rheum 1998;27:197–217. 4. Lee KS, Kim SJ, Lee BC, Yoon DS, Lee WJ, Chi HS. Surgical treatment of intestinal Behçet’s disease. Yonsei Med J 1997;38:455– 460. For submission instructions, please see the Gastroenterology website (http://www.gastrojournal.org).
Correction Shimizu K, Kobayashi M, Tahara J, Shiratori K. Cytokines and peroxisome proliferator-activated receptor ␥ ligand regulate phagocytosis by pancreatic stellate cells. Gastroenterology 2005;128:2105–2118.
The affiliation in the above article should have appeared as follows: *Departments of Gastroenterology and ‡Pathology, Tokyo Women’s Medical University, School of Medicine, Tokyo, Japan