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Interstitial pneumonitis:a rare but potentially fatal comlication of combination therapy
S210
Abstracts
Because of continued overt bleeding, enteroscopy via her colostomy was performed. As the scope was advanced beyond the terminal ileum, multiple areas of erythema with telangiectasias consistent with radiation enteritis were encountered. She has been managed conservatively with transfusions, iron, and erythropoietin, and is considering extensive distal small bowel resection. Conclusions: In patients with radiation colitis who have persistent hemorrhage despite aggressive therapy, one must consider investigating the coexistence of radiation enteritis.
631 ASSOCIATION BETWEEN PYEAR-OLDDERMA GANGRENOSUM AND ADENOCARCINOMA OF THE COLON? Douglas Lowe, M.D., Ayaz Chaudhary, M.D., Jeffrey Lee, M.D., Robert R. Schade, M.D.*. Medical College of Georgia, Augusta, GA and Veterans Administration Medical Center, Augusta, GA. The patient a 53 year-old Chinese male with PMH of hemorrhoids and skin lesions of unclear etiology presented with a history of several episodes of loose stool, bright red blood per rectum intermittently for six months, and a twenty-pound weight loss. He was not taking any medications. There was no history or family history of IBD or colon cancer. On examination: BP was 74/48, HR was 102, with orthostatic changes. The liver edge was not palpable. Lesions on his left leg were eight by six centimeters in size with patchy areas of hypo/hyper pigmentation, irregular central ulceration, erythema, granulation tissue, and had a foul odor and necrotic borders. He was also noted to have external and internal hemorrhoids with active bleeding per rectum. Laboratory results were: WBC 13,800/ml, neutrophils 70%, lymphocytes 23%, monocytes 6%, eosinophils 1%, hemoglobin 10.9 g/dl, MCV 78.7 ml, glucose 253 mg/dl, albumin 3.1 g/dl, and elevated WESR at 65 mm/hr. Serum protein electrophoresis, cryoglobulin testing, c-ANCA, and p-ANCA studies were obtained and subsequently found to be negative. Colonoscopy revealed a large annular mass in the rectum 5 cm from the anus extending 10 cm proximally. A second smaller, hard, non-circumferential and friable lesion in the ascending colon was also identified. The remainder of the colonoscopic exam was unremarkable with normal mucosal pattern. Biopsies of each mass revealed moderately differentiated adenocarcinoma. Abdominal CT confirmed the 2 masses and demonstrated hepatic metastasis. Skin lesion biopsy showed epidermal ulceration with acute and chronically inflamed granulation tissue in the bed of the ulcer consistent with pyoderma gangrenosum. The cancers were resected by a right hemicolectomy and abdominoperineal resection with an end descending colostomy. The resected bowel showed no evidence of IBD. At the time of a post-operative return visit his condition was stable but the skin lesions had not resolved. Pyoderma gangrenosum is a rare, idiopathic, inflammatory, ulcerative condition of the skin characterized by suppurative cutaneous ulcers that are edematous, bluish, boggy, and have necrotic borders as was initially described in 1916. Pyoderma gangrenosum occurs in up to five percent of patients with ulcerative colitis and two percent of those with Crohn’s disease. This case suggests that there may be an association between pyoderma gangrenosum and adenocarcinoma of the colon or rectum.
632 MULTIPLE COLONIC PSEUDOPOLYPOSIS DUE TO AMYLOIDOSIS; PRESENTING WITH LOWER GASTROINTESTINAL BLEED Richard L. Johnston, M.D., Gagan K. Sood, M.D.*, Maher Azzouz, M.D. University of MS Medical Center and V.A. Medical Center, Jackson, MS. Gastrointestinal involvement (mucosal or neuromuscular) is common in patients with primary and secondary amyloidosis. Mucosal lesions, ulcers or pseudopolypi (submucosal polyps) are commonly seen in stomach or
AJG – Vol. 98, No. 9, Suppl., 2003
proximal small bowel and are occasional source of overt or occult gastrointestinal bleed. We present a patient with diffuse polypoid lesions in colon presenting with lower gastrointestinal bleed. A 51 year-old healthy black male presented with one year history of intermittent hematochezia without any local or systemic symptoms. Physical exam was remarkable for palor without any peripheral lymphadenopathy or hepatosplenomegaly. Laboratory evaluation revealed Hct 23.0 ml/dl, MCV 65/ m3 Ferritin 12ng/ml, BUN 12mg/dl . Creatinine 1.0mg/dl. Serum electrophoresis was normal. Colonoscopy showed multiple polypoid lesions varying from 0.5 cm to 1.5 cms distributed throughout colon. Biopsy showed extensive submucosal amorphous eosinophilic material and positive staining with Congo red consistent with amyloidosis. Enteroscopic examination revealed extensive polypoid lesions in stomach and proximal small bowel. Cardiac echocardiogram was normal. Patient continued to have intermittent hematochezia requiring frequent blood transfusions and iron replacement. Gastrointestinal amyloidosis is a rare cause of gastrointestinal bleeding and colonic pseudopolypi due to submucosal amyloid deposit may manifest with lower gastrointestinal tract bleeding.
633 INTERSTITIAL PNEUMONITIS:A RARE BUT POTENTIALLY FATAL COMLICATION OF COMBINATION THERAPY Ayse Aytaman, M.D.*, Deepak Vadhan, M.D., Fidelina Desoto-Lapaix, M.D., Michael Cutaia, M.D., Ronny Awaida, M.D., JoAnn Comas, A.N.P., Lawrence Riccio, R.Ph., Gerald Fruchter, M.D. VA New York Harbor HCS, Brooklyn, NY and St Vincents Hospital, Staten Island, NY. Interferon based treatments offer chronic hepatitis C patients a hope for cure. Pulmonary complications of therapy are rare, but if they do occur, they are associated with significant morbidity and mortality. We describe here a case of severe interstitial pneumonia during pegylated interferon alpha 2b and ribavirin therapy. Case Report: A 52 year-old Vietnam War veteran, ex smoker, was found to have chronic hepatitis C. Liver biopsy revealed stage 3 fibrosis with moderate steatosis. Viral load was 1,599,910 copies with genotype 1b. He was treated with interferon alpha 2b and ribavirin with no significant virologic response for 48 weeks. He was started on pegylated interferon alpha 2b, 1.5 mcg/kg, and ribavirin 800 mg daily with baseline viral load of 512,415 copies per ml (223,500 IU/ML) and baseline ALT of 75 U/L. Baseline pulmonary function tests (PFT) revealed FEV1 (75%) and FVC (74.5%). At week 35, he presented with a 2-week history of increasing dyspnea. His hemoglobin was 12.5 g/dl, fairly stable. His exam was unremarkable, CXR revealed bilateral interstitial infiltrates. Combination therapy was discontinued immediately. Viral load at discontinuation was 164,165 copies (65,000 IU/ML). He was treated with bactrim and zithromax with some improvement in his symptoms. With persistent dyspnea though PFTs were repeated and revealed FEV1 (52%) and FVC (48%) with severe restrictive disease and a severe gas exchange abnormality. He underwent a diagnostic open lung biopsy, which revealed organizing diffuse alveolar damage (usual interstitial pneumonia). The patient was treated with steroids and is gradually improving at 4 week follow up. Repeat PFTs reveal FVC (56%) and FEV1 (59%). Conclusions: Dyspnea is a common symptom during combination therapy. Severe pulmonary complications of IFN, pegylated IFN and combination therapy are rare. Sarcoidosis, bronchiolitis obliterans, interstitial pneumonitis resulting in respiratory failure and even death have been reported. Clinicians should be aware of the implications of increasing dyspnea in the setting of adequate hemoglobin, as well as the appropriate approach to diagnosis and therapy.The CXR, spiral CT, lung biopsy, PFT results will be discussed with review of the literature.
Abstracts
Because of continued overt bleeding, enteroscopy via her colostomy was performed. As the scope was advanced beyond the terminal ileum, multiple areas of erythema with telangiectasias consistent with radiation enteritis were encountered. She has been managed conservatively with transfusions, iron, and erythropoietin, and is considering extensive distal small bowel resection. Conclusions: In patients with radiation colitis who have persistent hemorrhage despite aggressive therapy, one must consider investigating the coexistence of radiation enteritis.
631 ASSOCIATION BETWEEN PYEAR-OLDDERMA GANGRENOSUM AND ADENOCARCINOMA OF THE COLON? Douglas Lowe, M.D., Ayaz Chaudhary, M.D., Jeffrey Lee, M.D., Robert R. Schade, M.D.*. Medical College of Georgia, Augusta, GA and Veterans Administration Medical Center, Augusta, GA. The patient a 53 year-old Chinese male with PMH of hemorrhoids and skin lesions of unclear etiology presented with a history of several episodes of loose stool, bright red blood per rectum intermittently for six months, and a twenty-pound weight loss. He was not taking any medications. There was no history or family history of IBD or colon cancer. On examination: BP was 74/48, HR was 102, with orthostatic changes. The liver edge was not palpable. Lesions on his left leg were eight by six centimeters in size with patchy areas of hypo/hyper pigmentation, irregular central ulceration, erythema, granulation tissue, and had a foul odor and necrotic borders. He was also noted to have external and internal hemorrhoids with active bleeding per rectum. Laboratory results were: WBC 13,800/ml, neutrophils 70%, lymphocytes 23%, monocytes 6%, eosinophils 1%, hemoglobin 10.9 g/dl, MCV 78.7 ml, glucose 253 mg/dl, albumin 3.1 g/dl, and elevated WESR at 65 mm/hr. Serum protein electrophoresis, cryoglobulin testing, c-ANCA, and p-ANCA studies were obtained and subsequently found to be negative. Colonoscopy revealed a large annular mass in the rectum 5 cm from the anus extending 10 cm proximally. A second smaller, hard, non-circumferential and friable lesion in the ascending colon was also identified. The remainder of the colonoscopic exam was unremarkable with normal mucosal pattern. Biopsies of each mass revealed moderately differentiated adenocarcinoma. Abdominal CT confirmed the 2 masses and demonstrated hepatic metastasis. Skin lesion biopsy showed epidermal ulceration with acute and chronically inflamed granulation tissue in the bed of the ulcer consistent with pyoderma gangrenosum. The cancers were resected by a right hemicolectomy and abdominoperineal resection with an end descending colostomy. The resected bowel showed no evidence of IBD. At the time of a post-operative return visit his condition was stable but the skin lesions had not resolved. Pyoderma gangrenosum is a rare, idiopathic, inflammatory, ulcerative condition of the skin characterized by suppurative cutaneous ulcers that are edematous, bluish, boggy, and have necrotic borders as was initially described in 1916. Pyoderma gangrenosum occurs in up to five percent of patients with ulcerative colitis and two percent of those with Crohn’s disease. This case suggests that there may be an association between pyoderma gangrenosum and adenocarcinoma of the colon or rectum.
632 MULTIPLE COLONIC PSEUDOPOLYPOSIS DUE TO AMYLOIDOSIS; PRESENTING WITH LOWER GASTROINTESTINAL BLEED Richard L. Johnston, M.D., Gagan K. Sood, M.D.*, Maher Azzouz, M.D. University of MS Medical Center and V.A. Medical Center, Jackson, MS. Gastrointestinal involvement (mucosal or neuromuscular) is common in patients with primary and secondary amyloidosis. Mucosal lesions, ulcers or pseudopolypi (submucosal polyps) are commonly seen in stomach or
AJG – Vol. 98, No. 9, Suppl., 2003
proximal small bowel and are occasional source of overt or occult gastrointestinal bleed. We present a patient with diffuse polypoid lesions in colon presenting with lower gastrointestinal bleed. A 51 year-old healthy black male presented with one year history of intermittent hematochezia without any local or systemic symptoms. Physical exam was remarkable for palor without any peripheral lymphadenopathy or hepatosplenomegaly. Laboratory evaluation revealed Hct 23.0 ml/dl, MCV 65/ m3 Ferritin 12ng/ml, BUN 12mg/dl . Creatinine 1.0mg/dl. Serum electrophoresis was normal. Colonoscopy showed multiple polypoid lesions varying from 0.5 cm to 1.5 cms distributed throughout colon. Biopsy showed extensive submucosal amorphous eosinophilic material and positive staining with Congo red consistent with amyloidosis. Enteroscopic examination revealed extensive polypoid lesions in stomach and proximal small bowel. Cardiac echocardiogram was normal. Patient continued to have intermittent hematochezia requiring frequent blood transfusions and iron replacement. Gastrointestinal amyloidosis is a rare cause of gastrointestinal bleeding and colonic pseudopolypi due to submucosal amyloid deposit may manifest with lower gastrointestinal tract bleeding.
633 INTERSTITIAL PNEUMONITIS:A RARE BUT POTENTIALLY FATAL COMLICATION OF COMBINATION THERAPY Ayse Aytaman, M.D.*, Deepak Vadhan, M.D., Fidelina Desoto-Lapaix, M.D., Michael Cutaia, M.D., Ronny Awaida, M.D., JoAnn Comas, A.N.P., Lawrence Riccio, R.Ph., Gerald Fruchter, M.D. VA New York Harbor HCS, Brooklyn, NY and St Vincents Hospital, Staten Island, NY. Interferon based treatments offer chronic hepatitis C patients a hope for cure. Pulmonary complications of therapy are rare, but if they do occur, they are associated with significant morbidity and mortality. We describe here a case of severe interstitial pneumonia during pegylated interferon alpha 2b and ribavirin therapy. Case Report: A 52 year-old Vietnam War veteran, ex smoker, was found to have chronic hepatitis C. Liver biopsy revealed stage 3 fibrosis with moderate steatosis. Viral load was 1,599,910 copies with genotype 1b. He was treated with interferon alpha 2b and ribavirin with no significant virologic response for 48 weeks. He was started on pegylated interferon alpha 2b, 1.5 mcg/kg, and ribavirin 800 mg daily with baseline viral load of 512,415 copies per ml (223,500 IU/ML) and baseline ALT of 75 U/L. Baseline pulmonary function tests (PFT) revealed FEV1 (75%) and FVC (74.5%). At week 35, he presented with a 2-week history of increasing dyspnea. His hemoglobin was 12.5 g/dl, fairly stable. His exam was unremarkable, CXR revealed bilateral interstitial infiltrates. Combination therapy was discontinued immediately. Viral load at discontinuation was 164,165 copies (65,000 IU/ML). He was treated with bactrim and zithromax with some improvement in his symptoms. With persistent dyspnea though PFTs were repeated and revealed FEV1 (52%) and FVC (48%) with severe restrictive disease and a severe gas exchange abnormality. He underwent a diagnostic open lung biopsy, which revealed organizing diffuse alveolar damage (usual interstitial pneumonia). The patient was treated with steroids and is gradually improving at 4 week follow up. Repeat PFTs reveal FVC (56%) and FEV1 (59%). Conclusions: Dyspnea is a common symptom during combination therapy. Severe pulmonary complications of IFN, pegylated IFN and combination therapy are rare. Sarcoidosis, bronchiolitis obliterans, interstitial pneumonitis resulting in respiratory failure and even death have been reported. Clinicians should be aware of the implications of increasing dyspnea in the setting of adequate hemoglobin, as well as the appropriate approach to diagnosis and therapy.The CXR, spiral CT, lung biopsy, PFT results will be discussed with review of the literature.