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Medication-induced esophageal tattoo in a patient with eosinophilic esophagitis
AT THE FOCAL POINT Lawrence J. Brandt, MD, Associate Editor for Focal Points
Medication-induced esophageal tattoo in a patient with eosinophilic esophagitis
A 51-year-old white man with a history of repeated esophageal food impactions presented to the outpatient endoscopy center for evaluation of dysphagia. Upper endoscopy was performed, and visible lettering was encountered in the mid-esophagus giving the appearance of a tattoo. The lettering was clearly legible as “West Ward 3000” on each side of the esophagus (A, B). No foreign body or pill was seen the esophagus or stomach. Transverse ridging consistent with eosinophilic esophagitis was seen in the mid and distal esophagus without evidence of ulceration or pill esophagitis (C). Research revealed that the lettering seen was from a generic form of Fioricet. After the procedure, the patient admitted to taking this medication for migraine headaches but that he had not disclosed 154 GASTROINTESTINAL ENDOSCOPY
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this on his intake history. Mucosal biopsy samples later confirmed an increased number of intraepithelial eosinophils (15 per high-power field) consistent with the diagnosis of eosinophilic esophagitis.
DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Matthew N. Thoma, MD, Alison Schneider, MD, Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida doi:10.1016/j.gie.2010.05.031
www.giejournal.org
At the Focal Point
Commentary The practice of tattooing has been documented to exist since Neolithic times. The first use of the term tattoo has been attributed to Joseph Banks, the naturalist aboard Cook’s ship the “Endeavour” in 1769, although the word tattoo likely was taken from the Polynesian tatau. In fact, however, the verbiage in this case was not really tattooed into the esophagus, but rather merely transferred onto the mucosa, and, therefore, likely will not cause any difficulty. Nonetheless, the transfer, or perhaps decal, West Ward 3000 did serve a worthwhile practice because it is objective evidence that the patient ingested at least 1 tablet of generic Fioricet (acetaminophen 325 mg, butalbital 50 mg, caffeine 40 mg, codeine 30 mg). The agents in the transfer are of no concern: The capsule shell contains FD&C Blue No. 2 (an indigo dye), FD&C Red No. 3 (erythrocin, a fluorescein derivative), red and yellow iron oxides, and titanium dioxide. The letters themselves are of titanium dioxide. We all should know about the designation FD&C, which refers to the Federal Food, Drug, and Cosmetic Act, passed in 1938 after the death of more than 100 patients caused by diethylene glycol poisoning, a dissolution agent used in the preparation of a sulfanilamide medication. I was particularly interested in this case because the “Fiore” in Fiorinol and Fioricet is derived from Montefiore, my home-base hospital, where Fiorinal was developed. I also appreciated the use of endoscopy to derive unobtained history. Often at colonoscopy we learn that patients have a history of constipation or laxative abuse when we see melanosis coli; here, we learned by EGD that the patient had a history of migraines. Now that’s an endoscopy! Lawrence J. Brandt, MD Associate Editor for Focal Points
Esophageal squamous cell carcinoma with intramural metastasis presenting as a pendiculated polyp An 80-year-old man presented at our institution with a recent onset of fever and loss of appetite. Physical examination revealed palpable lymph nodes over the left side of the neck. Laboratory data included a white blood cell count of 15,800/mm3 (normal 4500-10,000/mm3), an elevated lactate dehydrogenase level of 9880 U/L (normal ⬍230 U/L), and a decreased albumin level of 2.7 g/dL (normal 3.5-5.0 g/dL). EGD disclosed a pendiculated polyp with a hyperemic nodular surface in the cervical esophagus (A); multiple mucosal elevations proximal to the polyp also were noted (B). Histopathologic examination of the biopsy specimens from the polyp showed squamous cell carcinoma (C), whereas the adjacent mucosal elevations demonstrated intramural metastasis (D). A diagnosis of esophageal squamous cell carcinoma with intramural metastasis was made. The patient died of pneumonia and sepsis 1 week later. Autopsy was not permitted.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Sheng-Lei Yan, MD, Division of Gastroenterology, Department of Internal Medicine, Chang Bing Show-Chwan Memorial Hospital, Graduate Institute of Bioindustrial Technology, DaYeh University, Changhua County, Taiwan, Republic of China, Ming-Tsung Lai, MD, Department of Pathology, Chang Bing Show-Chwan Memorial Hospital, Taiwan, Republic of China, Yueh-Tsung Lee, MD, Division of General Surgery, Department of Surgery, Chang Bing Show-Chwan Memorial Hospital, Department of Life Sciences, National Chung Hsing University, Taichung City, Taiwan, Republic of China doi:10.1016/j.gie.2010.06.047
Commentary Adenocarcinoma (of the distal esophagus) is the most common histologic type of esophageal cancer in the West, whereas squamous cell carcinoma (in the midthoracic esophagus) predominates in the East. Intramural metastasis usually is associated with a poor prognosis, but if close to the parent tumor, as in the present case, survival may not be as adversely affected as when such metastasis is farther away. To understand intramural spread and lymph node involvement, a bit of an understanding of anatomy is needed. The esophagus is unique in that there is a rich presence of lymphatics in the lamina propria and muscularis mucosa. In esophageal carcinoma, lymphatic metastases may develop by 1 of 3 routes: longitudinally along the submucosa to regional and nonregional lymph nodes, perpendicularly through the muscularis propria to the regional nodes, or perpendicularly through the muscularis mucosa to the thoracic duct and the systemic venous circulation. The lymphatic channels of the esophagus run along the axis of the esophagus, some draining superiorly into the cervical lymph nodes upward and some inferiorly to the abdominal nodes. Thus, mediastinal, cervical, and upper abdominal (subdiaphragmatic, celiac, and hepatic www.giejournal.org
Volume 73, No. 1 : 2011 GASTROINTESTINAL ENDOSCOPY
155
Medication-induced esophageal tattoo in a patient with eosinophilic esophagitis
A 51-year-old white man with a history of repeated esophageal food impactions presented to the outpatient endoscopy center for evaluation of dysphagia. Upper endoscopy was performed, and visible lettering was encountered in the mid-esophagus giving the appearance of a tattoo. The lettering was clearly legible as “West Ward 3000” on each side of the esophagus (A, B). No foreign body or pill was seen the esophagus or stomach. Transverse ridging consistent with eosinophilic esophagitis was seen in the mid and distal esophagus without evidence of ulceration or pill esophagitis (C). Research revealed that the lettering seen was from a generic form of Fioricet. After the procedure, the patient admitted to taking this medication for migraine headaches but that he had not disclosed 154 GASTROINTESTINAL ENDOSCOPY
Volume 73, No. 1 : 2011
this on his intake history. Mucosal biopsy samples later confirmed an increased number of intraepithelial eosinophils (15 per high-power field) consistent with the diagnosis of eosinophilic esophagitis.
DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Matthew N. Thoma, MD, Alison Schneider, MD, Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida doi:10.1016/j.gie.2010.05.031
www.giejournal.org
At the Focal Point
Commentary The practice of tattooing has been documented to exist since Neolithic times. The first use of the term tattoo has been attributed to Joseph Banks, the naturalist aboard Cook’s ship the “Endeavour” in 1769, although the word tattoo likely was taken from the Polynesian tatau. In fact, however, the verbiage in this case was not really tattooed into the esophagus, but rather merely transferred onto the mucosa, and, therefore, likely will not cause any difficulty. Nonetheless, the transfer, or perhaps decal, West Ward 3000 did serve a worthwhile practice because it is objective evidence that the patient ingested at least 1 tablet of generic Fioricet (acetaminophen 325 mg, butalbital 50 mg, caffeine 40 mg, codeine 30 mg). The agents in the transfer are of no concern: The capsule shell contains FD&C Blue No. 2 (an indigo dye), FD&C Red No. 3 (erythrocin, a fluorescein derivative), red and yellow iron oxides, and titanium dioxide. The letters themselves are of titanium dioxide. We all should know about the designation FD&C, which refers to the Federal Food, Drug, and Cosmetic Act, passed in 1938 after the death of more than 100 patients caused by diethylene glycol poisoning, a dissolution agent used in the preparation of a sulfanilamide medication. I was particularly interested in this case because the “Fiore” in Fiorinol and Fioricet is derived from Montefiore, my home-base hospital, where Fiorinal was developed. I also appreciated the use of endoscopy to derive unobtained history. Often at colonoscopy we learn that patients have a history of constipation or laxative abuse when we see melanosis coli; here, we learned by EGD that the patient had a history of migraines. Now that’s an endoscopy! Lawrence J. Brandt, MD Associate Editor for Focal Points
Esophageal squamous cell carcinoma with intramural metastasis presenting as a pendiculated polyp An 80-year-old man presented at our institution with a recent onset of fever and loss of appetite. Physical examination revealed palpable lymph nodes over the left side of the neck. Laboratory data included a white blood cell count of 15,800/mm3 (normal 4500-10,000/mm3), an elevated lactate dehydrogenase level of 9880 U/L (normal ⬍230 U/L), and a decreased albumin level of 2.7 g/dL (normal 3.5-5.0 g/dL). EGD disclosed a pendiculated polyp with a hyperemic nodular surface in the cervical esophagus (A); multiple mucosal elevations proximal to the polyp also were noted (B). Histopathologic examination of the biopsy specimens from the polyp showed squamous cell carcinoma (C), whereas the adjacent mucosal elevations demonstrated intramural metastasis (D). A diagnosis of esophageal squamous cell carcinoma with intramural metastasis was made. The patient died of pneumonia and sepsis 1 week later. Autopsy was not permitted.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Sheng-Lei Yan, MD, Division of Gastroenterology, Department of Internal Medicine, Chang Bing Show-Chwan Memorial Hospital, Graduate Institute of Bioindustrial Technology, DaYeh University, Changhua County, Taiwan, Republic of China, Ming-Tsung Lai, MD, Department of Pathology, Chang Bing Show-Chwan Memorial Hospital, Taiwan, Republic of China, Yueh-Tsung Lee, MD, Division of General Surgery, Department of Surgery, Chang Bing Show-Chwan Memorial Hospital, Department of Life Sciences, National Chung Hsing University, Taichung City, Taiwan, Republic of China doi:10.1016/j.gie.2010.06.047
Commentary Adenocarcinoma (of the distal esophagus) is the most common histologic type of esophageal cancer in the West, whereas squamous cell carcinoma (in the midthoracic esophagus) predominates in the East. Intramural metastasis usually is associated with a poor prognosis, but if close to the parent tumor, as in the present case, survival may not be as adversely affected as when such metastasis is farther away. To understand intramural spread and lymph node involvement, a bit of an understanding of anatomy is needed. The esophagus is unique in that there is a rich presence of lymphatics in the lamina propria and muscularis mucosa. In esophageal carcinoma, lymphatic metastases may develop by 1 of 3 routes: longitudinally along the submucosa to regional and nonregional lymph nodes, perpendicularly through the muscularis propria to the regional nodes, or perpendicularly through the muscularis mucosa to the thoracic duct and the systemic venous circulation. The lymphatic channels of the esophagus run along the axis of the esophagus, some draining superiorly into the cervical lymph nodes upward and some inferiorly to the abdominal nodes. Thus, mediastinal, cervical, and upper abdominal (subdiaphragmatic, celiac, and hepatic www.giejournal.org
Volume 73, No. 1 : 2011 GASTROINTESTINAL ENDOSCOPY
155