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Unusual endoscopic features of gastric and duodenal cryptosporidiosis in AIDS
omy of the biliary tree to avoid injuries during cholecystectomy and misinterpretation of cholangiographic findings. 5 Also, in cases of persistent and unexplained cholangitis, jaundice, and abscesses, biliary duct anomalies should be considered. 6
REFERENCES 1. Savader SJ, Venbrux AC, Faerber EN, Friedman AC. Biliary tract anomalies, congenital and neonatal disorders, and hepatobiliary cystic malformations. In: Friedman AC, Dachman AH, editors. Radiology of the liver, biliary tract, and pancreas. St. Louis: Mosby, 1994:397-443.
Unusual endoscopic features of gastric and duodenal cryptosporidiosis in AIDS Naga Chalasani, MD Audrey J. Lazenby, MD C. Mel Wilcox, MD O p p o r t u n i s t i c infections of t h e g a s t r o i n t e s t i n a l t r a c t f r e q u e n t l y complicate t h e acquired i m m u n o d e f i c i e n c y s y n d r o m e (AIDS). T h e m o s t c o m m o n g a s t r o i n t e s t i n a l infections s e e n in p a t i e n t s w i t h A I D S include fungal a n d viral d i s e a s e s of the e s o p h a g u s , p a r a s i t i c infections of t h e s m a l l bowel, a n d c y t o m e g a l o v i r u s colitis. E n d o s c o p y p l a y s a n i n v a l u a b l e role in t h e e v a l u a t i o n of h u m a n i m m u n o d e f i c i e n c y v i r u s (HIV)-infected pat i e n t s w i t h g a s t r o i n t e s t i n a l s y m p t o m s , given t h e necessity for m u c o s a l biopsy to diagnosis m a n y of t h e s e disorders. W i t h s o m e of t h e s e infections, endoscopic findings h a v e b e e n described t h a t a p p e a r to be characteristic for specific p a t h o g e n s . We r e p o r t t h r e e p a t i e n t s w i t h g a s t r i c and/or d u o d e n a l cryptosporidiosis w i t h endoscopic f e a t u r e s t h a t h a v e not b e e n previously described. CASE REPORTS Case 1 A 33-year-old man with a 16-month history of intestinal cryptosporidiosis complicated by sclerosing cholangitis and papillary stenosis requiring endoscopic sphincterotomy presented with a 3-week history of nausea and vomiting of copious amounts of greenish fluid. He also reported occasional emesis of old food. Associated symptoms included early sa-
From the Department of Medicine, Emory University School of Medicine, the Medical Service of Grady Memorial Hospital, Atlanta, Georgia; and the Departments of Medicine and Pathology, University of Alabama at Birmingham, Birmingham, Alabama. Reprint requests: C. Mel Wilcox, MD, University of Alabama Birmingham, Gastroenterology and Hepatology, UAB Station, Birmingham, AL 35294-0007. 0016-5107/97/4506-052555.00 +0 GASTROINTESTINAL ENDOSCOPY Copyright © 1997 by the American Societyfor Gastrointestinal Endoscopy
37/4/81018 VOLUME 45, NO. 6, 1997
2. Hand BH. Anatomy and embryology of the biliary tract and pancreas. In: Sivak MV, editor. Gastroenterologic endoscopy. Philadelphia: WB Saunders, 1987:599-618. 3. Brandt CP, Eckhauser ML. Rare bile duct anomalies. A case report and implications for laparoscopic cholecystectomy. Surg Endosc 1994;8:329-31. 4. Gibney RG, Nichols DM, Osborne JC, Fache JS, Burhenne HJ. Interhepatic duct: a new biliary anomaly. Gastrointest Radiol 1987;12:134-6. 5. Christensen RA, vanSonnenberg E, Nemcek AA Jr, D'Agostino HB. Inadvertent ligation of the aberrant right hepatic duct at cholecsytectomy: radiologic diagnosis and therapy. Radiology 1992;183:549-53. 6. Rizzo RJ, Szucs RA, Turner MA. Congenital abnormalities of the pancreas and biliary tree in adults. Radiographics 1995;15: 49-68.
tiety, severe diarrhea associated with manifestations of dehydration, and weight loss. Physical examination was remarkable for a succussion splash. Endoscopic examination revealed a marked amount of bilious fluid in the stomach associated with severe erosive gastritis involving the gastric antrum (Fig. 1A) as well as edema and nodularity of the duodenum, including the bulb. The intestinal mucosa was covered with multiple whitish plaques (Fig. 1B). Biopsies of the antrum showed numerous cryptosporidia and a marked inflammatory response including erosions, reactive epithelinm, numerous plasma cells in the lamina propria, and scattered neutrophils. Helicobacter pylori was absent by routine and special staining. Biopsies of the duodenum revealed numerous cryptosporidia (Fig. 1C) as well as villous blunting, reactive epithelium, and increased plasma cells in the lamina propria. There was no evidence of other pathogens including cytomegalovirus on routine and special staining. Case 2 A 36-year-old man with AIDS was evaluated for dysphagia and diarrhea. He had a past history of cryptosporidiosis identified by stool studies 10 months previously. Upper endoscopy revealed Candida esophagitis. In the second and third portions of the duodenum, the valx~lae conniventes appeared to have an irregular serrated appearance with some loss of mucosal fblds and submucosal blood vessels (Fig. 2). Multiple biopsy specimens were obtained of the duodenum that revealed severe cryptosporidial enteritis and marked villous atrophy and no other pathogens. Case 3 A 34-year-old man with a 6-month history of AIDS was admitted for evaluation of deep venous thrombosis. At the time of admission, dysphagia, epigastric abdominal pain, and diarrhea were reported. Upper endoscopy revealed several well-circumscribed esophageal ulcers and multiple small well-circumscribed erosions in the duodenal bulb that were typical for acid-peptic disease (Fig. 3). The junction of the first and second duodenum was markedly edematous, barely permitting passage of the endoscope; the second duodenum appeared endoscopically normal. Multiple biopsy specimens were obtained of the duodenal bulb. Histopathologic examination of the mucosal biopsy specimens demonstrated an active enteritis with prominent cryptosporidial involvement without any other pathogens. GASTROINTESTINAL ENDOSCOPY 525
Figure 2. Irregular serrated appearance of a valvulae conniventes in the proximal portion of the second duodenum.
Figure 3. Edema and multiple erosions of the duodenal bulb mimicking acid-peptic disease.
Figure 1. A, Circumferential erosive changes and narrowing of the gastric antrum. B, Multiple white plaques coating the mucosa of the second duodenum. C, Numerous cryptosporidial organisms dotting the crypt and surface epithelium of the duodenum. (H&E, original magnification x400.) DISCUSSION Cryptosporidiosis is one of the most common causes of diarrhea in patients with AIDS. Although cryptosporidiosis can be found in any portion of the gastrointestinal tract, including the hepatobiliary tree and pancreas, the small bowel is the most common site of infection. Intestinal cryptosporidiosis typically does not result in any demonstrable endoscopic abnormalities. In a study of duodenal morphology in patients with 526
GASTROINTESTINAL ENDOSCOPY
intestinal cryptosporidiosis, duodenal villous architecture was normal in most patients. 1 In a series of 19 patients with AIDS and intestinal cryptosporidiosis, Kotler et al. 2 described 1 patient in whom the small bowel appeared erythematous with an overlying milky exudate, although endoscopic documentation was not provided. Given the study design, it is unclear whether these endoscopic findings were of the duodenum or jejunum. Papp et al.3 recently reported a case of duodenal cryptosporidiosis in AIDS in which there were white plaques of the duodenum similar to Case 1 in our series. In t h a t report, 3 the pathologic findings were also similar to those identified in our patient. Another case of cryptosporidial gastroduodenitis was described by Dworkin et al.4; however, no endoscopic description or photographic documentation was provided. Other case series of patients with AIDS and cryptosporidiosis do not describe endoscopic abnormalities of the duodenum. 5, 6 Likewise, in the HIVseronegative patients with intestinal cryptosporidiosis found by routine endoscopy, none of the patients VOLUME 45, NO. 6, 1997
w i t h d u o d e n a l cryptosporidiosis h a d a b n o r m a l i t i e s at endoscopy of t h e d u o d e n u m . 7 Cryptosporidiosis h a s b e e n r e p o r t e d as a c a u s e of isolated a n t r a l n a r r o w i n g on b a r i u m u p p e r gast r o i n t e s t i n a l series; however, endoscopy failed to reveal a n y erosions, ulcerations, or obvious d e f o r m i t y except for diffuse a n t r a l e r y t h e m a s or friability a n d t h i c k e n e d folds. 9 I n contrast, one of o u r p a t i e n t s pres e n t e d w i t h m a r k e d endoscopic a b n o r m a l i t i e s including a n t r a l n a r r o w i n g a n d gastric outlet obstruction. O f our p a t i e n t s w i t h d u o d e n a l i n v o l v e m e n t , one h a d a s e r r a t e d a p p e a r a n c e of t h e d u o d e n a l m u c o s a a n d n o d u l a r i t y of t h e d u o d e n a l folds. I n a n o t h e r patient, erosive duodenitis, m i m i c k i n g acid-peptic disease, resulted f r o m t h e i n t e n s e i n f l a m m a t o r y r e s p o n s e c a u s e d b y cryptosporidiosis. I n t h e l a s t p a t i e n t , t h e p l a q u e s r e s e m b l e d s o m e w h a t t h e a p p e a r a n c e of d u o d e n a l M y c o b a c t e r i u m a v i u m complex. I n this condition, however, t h e i n t e s t i n a l lesions a r e u s u a l l y larger, m o r e p a p u l a r , a n d h a v e a yellowish color. 1° T h e endoscopic f e a t u r e s we identified could not be c o r r e l a t e d w i t h t h e histopathologic findings, b u t t h e y a r e p r o b a b l y in some w a y r e l a t e d to t h e severe i n f l a m m a t o r y process. H o w e v e r , b e c a u s e effective t h e r a p y for cryptosporidial disease is lacking, we c a n n o t p r o v e definitively t h a t t h e identified endoscopic a b n o r m a l i t i e s w e r e c a u s e d b y cryptosporidiosis. O u r cases f u r t h e r e x t e n d t h e s p e c t r u m of endoscopic a b n o r m a l i t i e s c a u s e d b y opportunistic infections in p a t i e n t s w i t h A I D S a n d e m p h a s i z e s t h e n e e d for m u -
cosal biopsy of all endoscopic lesions in the a p p r o p r i ate clinical setting.
Gastric purpura: an unusual endoscopic feature in gastrointestinal hemorrhage
rhage, 2 b u t p u r p u r a in the s t o m a c h is r a r e l y s e e n d u r i n g endoscopy. We r e p o r t two cases of gastric purp u r a associated w i t h acute g a s t r o i n t e s t i n a l h e m o r rhage.
Ronald Hsu, MD Tedessa Desta, MD Joseph Leung, MD, FRCP Acute u p p e r g a s t r o i n t e s t i n a l h e m o r r h a g e is comm o n l y due to g a s t r o d u o d e n a l ulcers, varices, Mallory Weiss t e a r , congestive g a s t r o p a t h y , esophagitis, Dieulafoy's lesions, a n d a r t e r i o v e n o u s m a l f o r m a t i o n s . 1 V a r i o u s m u c o s a l f e a t u r e s such as petechiae, ecchymosis, erosions, a n d u l c e r a t i o n s h a v e b e e n described in p a t i e n t s w i t h a c u t e u p p e r g a s t r o i n t e s t i n a l h e m o r From the Division of Gastroenterology, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California. Reprint requests: Ronald Hsu, MD, Gastroenterology, 4301 & X Street, Professional Building Room 2040, University of California, Davis Medical Center, Sacramento, CA 95817. oo16-5107/97/45o6-o52755.o0 +0 GASTROINTESTINAL ENDOSCOPY Copyright © 1997 by the American Societyfor Gastrointestinal Endoscopy 37/4/81017
VOLUME 45, NO. 6, 1997
REFERENCES 1. Genta RM, Chappell CL, White AC Jr, Kimball KT, Goodgame RW. Duodenal morphology and intensity of infection in AIDSrelated intestinal cryptesporidiosis. Gastroenterology 1993; 105:1769-75. 2. Kotler DP, Francisco A, Clayton F, Scholes JV. Small intestinal injury and parasitic diseases in AIDS. Ann Intern Med 1990;113:444-9. 3. Papp JP Jr, De Young BR, Fromkes JJ. Endoscopic appearance of cryptosporidial duodenitis. Am J Gastroenterol 1996;91: 2235-6. 4. Dworkin B, Wormser GP, Rosenthal WS, Heier SK, Braunstein M, Weiss L, et al. Gastrointestinal manifestations of the acquired immunodeficiency syndrome. A review of 22 cases. Am J Gastroenterol 1985;80:774-8. 5. Connolly GM, Dryden MS, Shanson DC, Gazzard BG. Cryptosporidial diarrhoea in AIDS and its treatment. Gut 1988;29:593-7. 6. McGowan I, Hawkins AS, Weller IVD. The natural history of cryptesporidial diarrhoea in HIV-infected patients. AIDS 1993; 7:349-54. 7. Roberts WG, Green PH, Ma J, Carr M, Ginsberg AM. Prevalence of cryptosporidiosis in patients undergoing endoscopy: evidence for an asymptomatic carrier state. Am J Med 1989; 87:537-9. 8. Cersosimo E, Wilkowse CJ, Rosenblatt JE, Ludwig J. Isolated antral narrowing associated with gastrointestinal cryptospordiosis in acquired immunodeficiency syndrome. Mayo Clin Proc 1992;67:553-6. 9. Massimillo AJ, Chang J, Freedman L, Baxi R, Kanth N, Pellecchia C. Cryptosporidium gastropathy: presentation of a case and review of the literature. Dig Dis Sci 1995;40:186-90. 10. WilcoxCM. Duodenum and small bowel. In: WilcoxCM, editor. Atlas of clinical gastrointestinal endoscopy. Philadelphia: WB Saunders, 1995:194.
CASE REPORTS Case 1 An 87-year-old man presented to the emergency department. He had had a flu-like illness for a few days and had passed a cup of bright-red bloody emesis. He denied any abdominal pain. He had a remote history of peptic ulcer disease but was not on any maintenance therapy at presentation. There was no usage of aspirin or nonsteroidal antiinflammatory agent for at least 6 months prior to admission. He did not smoke or use alcohol. There was no history of liver disease. On admission, he was orthostatic and was noted to have multiple flat purpuric lesions on both legs. There were no signs of chronic liver disease such as spider angioma, hepatosplenomegaly, or jaundice. The abdomen was soft and nontender, and the rectal examination showed red-tinged stool. His blood tests revealed a very low platelet count of 5000 (normal: 130,000 to 400,000/ram3). The hemoglobin level was 6.7 (14 to 18 gm/dl), white blood cell count was 11,400 (4,800 to 10,800/ram3), INR was 1.03, partial thromGASTROINTESTINAL ENDOSCOPY 527
REFERENCES 1. Savader SJ, Venbrux AC, Faerber EN, Friedman AC. Biliary tract anomalies, congenital and neonatal disorders, and hepatobiliary cystic malformations. In: Friedman AC, Dachman AH, editors. Radiology of the liver, biliary tract, and pancreas. St. Louis: Mosby, 1994:397-443.
Unusual endoscopic features of gastric and duodenal cryptosporidiosis in AIDS Naga Chalasani, MD Audrey J. Lazenby, MD C. Mel Wilcox, MD O p p o r t u n i s t i c infections of t h e g a s t r o i n t e s t i n a l t r a c t f r e q u e n t l y complicate t h e acquired i m m u n o d e f i c i e n c y s y n d r o m e (AIDS). T h e m o s t c o m m o n g a s t r o i n t e s t i n a l infections s e e n in p a t i e n t s w i t h A I D S include fungal a n d viral d i s e a s e s of the e s o p h a g u s , p a r a s i t i c infections of t h e s m a l l bowel, a n d c y t o m e g a l o v i r u s colitis. E n d o s c o p y p l a y s a n i n v a l u a b l e role in t h e e v a l u a t i o n of h u m a n i m m u n o d e f i c i e n c y v i r u s (HIV)-infected pat i e n t s w i t h g a s t r o i n t e s t i n a l s y m p t o m s , given t h e necessity for m u c o s a l biopsy to diagnosis m a n y of t h e s e disorders. W i t h s o m e of t h e s e infections, endoscopic findings h a v e b e e n described t h a t a p p e a r to be characteristic for specific p a t h o g e n s . We r e p o r t t h r e e p a t i e n t s w i t h g a s t r i c and/or d u o d e n a l cryptosporidiosis w i t h endoscopic f e a t u r e s t h a t h a v e not b e e n previously described. CASE REPORTS Case 1 A 33-year-old man with a 16-month history of intestinal cryptosporidiosis complicated by sclerosing cholangitis and papillary stenosis requiring endoscopic sphincterotomy presented with a 3-week history of nausea and vomiting of copious amounts of greenish fluid. He also reported occasional emesis of old food. Associated symptoms included early sa-
From the Department of Medicine, Emory University School of Medicine, the Medical Service of Grady Memorial Hospital, Atlanta, Georgia; and the Departments of Medicine and Pathology, University of Alabama at Birmingham, Birmingham, Alabama. Reprint requests: C. Mel Wilcox, MD, University of Alabama Birmingham, Gastroenterology and Hepatology, UAB Station, Birmingham, AL 35294-0007. 0016-5107/97/4506-052555.00 +0 GASTROINTESTINAL ENDOSCOPY Copyright © 1997 by the American Societyfor Gastrointestinal Endoscopy
37/4/81018 VOLUME 45, NO. 6, 1997
2. Hand BH. Anatomy and embryology of the biliary tract and pancreas. In: Sivak MV, editor. Gastroenterologic endoscopy. Philadelphia: WB Saunders, 1987:599-618. 3. Brandt CP, Eckhauser ML. Rare bile duct anomalies. A case report and implications for laparoscopic cholecystectomy. Surg Endosc 1994;8:329-31. 4. Gibney RG, Nichols DM, Osborne JC, Fache JS, Burhenne HJ. Interhepatic duct: a new biliary anomaly. Gastrointest Radiol 1987;12:134-6. 5. Christensen RA, vanSonnenberg E, Nemcek AA Jr, D'Agostino HB. Inadvertent ligation of the aberrant right hepatic duct at cholecsytectomy: radiologic diagnosis and therapy. Radiology 1992;183:549-53. 6. Rizzo RJ, Szucs RA, Turner MA. Congenital abnormalities of the pancreas and biliary tree in adults. Radiographics 1995;15: 49-68.
tiety, severe diarrhea associated with manifestations of dehydration, and weight loss. Physical examination was remarkable for a succussion splash. Endoscopic examination revealed a marked amount of bilious fluid in the stomach associated with severe erosive gastritis involving the gastric antrum (Fig. 1A) as well as edema and nodularity of the duodenum, including the bulb. The intestinal mucosa was covered with multiple whitish plaques (Fig. 1B). Biopsies of the antrum showed numerous cryptosporidia and a marked inflammatory response including erosions, reactive epithelinm, numerous plasma cells in the lamina propria, and scattered neutrophils. Helicobacter pylori was absent by routine and special staining. Biopsies of the duodenum revealed numerous cryptosporidia (Fig. 1C) as well as villous blunting, reactive epithelium, and increased plasma cells in the lamina propria. There was no evidence of other pathogens including cytomegalovirus on routine and special staining. Case 2 A 36-year-old man with AIDS was evaluated for dysphagia and diarrhea. He had a past history of cryptosporidiosis identified by stool studies 10 months previously. Upper endoscopy revealed Candida esophagitis. In the second and third portions of the duodenum, the valx~lae conniventes appeared to have an irregular serrated appearance with some loss of mucosal fblds and submucosal blood vessels (Fig. 2). Multiple biopsy specimens were obtained of the duodenum that revealed severe cryptosporidial enteritis and marked villous atrophy and no other pathogens. Case 3 A 34-year-old man with a 6-month history of AIDS was admitted for evaluation of deep venous thrombosis. At the time of admission, dysphagia, epigastric abdominal pain, and diarrhea were reported. Upper endoscopy revealed several well-circumscribed esophageal ulcers and multiple small well-circumscribed erosions in the duodenal bulb that were typical for acid-peptic disease (Fig. 3). The junction of the first and second duodenum was markedly edematous, barely permitting passage of the endoscope; the second duodenum appeared endoscopically normal. Multiple biopsy specimens were obtained of the duodenal bulb. Histopathologic examination of the mucosal biopsy specimens demonstrated an active enteritis with prominent cryptosporidial involvement without any other pathogens. GASTROINTESTINAL ENDOSCOPY 525
Figure 2. Irregular serrated appearance of a valvulae conniventes in the proximal portion of the second duodenum.
Figure 3. Edema and multiple erosions of the duodenal bulb mimicking acid-peptic disease.
Figure 1. A, Circumferential erosive changes and narrowing of the gastric antrum. B, Multiple white plaques coating the mucosa of the second duodenum. C, Numerous cryptosporidial organisms dotting the crypt and surface epithelium of the duodenum. (H&E, original magnification x400.) DISCUSSION Cryptosporidiosis is one of the most common causes of diarrhea in patients with AIDS. Although cryptosporidiosis can be found in any portion of the gastrointestinal tract, including the hepatobiliary tree and pancreas, the small bowel is the most common site of infection. Intestinal cryptosporidiosis typically does not result in any demonstrable endoscopic abnormalities. In a study of duodenal morphology in patients with 526
GASTROINTESTINAL ENDOSCOPY
intestinal cryptosporidiosis, duodenal villous architecture was normal in most patients. 1 In a series of 19 patients with AIDS and intestinal cryptosporidiosis, Kotler et al. 2 described 1 patient in whom the small bowel appeared erythematous with an overlying milky exudate, although endoscopic documentation was not provided. Given the study design, it is unclear whether these endoscopic findings were of the duodenum or jejunum. Papp et al.3 recently reported a case of duodenal cryptosporidiosis in AIDS in which there were white plaques of the duodenum similar to Case 1 in our series. In t h a t report, 3 the pathologic findings were also similar to those identified in our patient. Another case of cryptosporidial gastroduodenitis was described by Dworkin et al.4; however, no endoscopic description or photographic documentation was provided. Other case series of patients with AIDS and cryptosporidiosis do not describe endoscopic abnormalities of the duodenum. 5, 6 Likewise, in the HIVseronegative patients with intestinal cryptosporidiosis found by routine endoscopy, none of the patients VOLUME 45, NO. 6, 1997
w i t h d u o d e n a l cryptosporidiosis h a d a b n o r m a l i t i e s at endoscopy of t h e d u o d e n u m . 7 Cryptosporidiosis h a s b e e n r e p o r t e d as a c a u s e of isolated a n t r a l n a r r o w i n g on b a r i u m u p p e r gast r o i n t e s t i n a l series; however, endoscopy failed to reveal a n y erosions, ulcerations, or obvious d e f o r m i t y except for diffuse a n t r a l e r y t h e m a s or friability a n d t h i c k e n e d folds. 9 I n contrast, one of o u r p a t i e n t s pres e n t e d w i t h m a r k e d endoscopic a b n o r m a l i t i e s including a n t r a l n a r r o w i n g a n d gastric outlet obstruction. O f our p a t i e n t s w i t h d u o d e n a l i n v o l v e m e n t , one h a d a s e r r a t e d a p p e a r a n c e of t h e d u o d e n a l m u c o s a a n d n o d u l a r i t y of t h e d u o d e n a l folds. I n a n o t h e r patient, erosive duodenitis, m i m i c k i n g acid-peptic disease, resulted f r o m t h e i n t e n s e i n f l a m m a t o r y r e s p o n s e c a u s e d b y cryptosporidiosis. I n t h e l a s t p a t i e n t , t h e p l a q u e s r e s e m b l e d s o m e w h a t t h e a p p e a r a n c e of d u o d e n a l M y c o b a c t e r i u m a v i u m complex. I n this condition, however, t h e i n t e s t i n a l lesions a r e u s u a l l y larger, m o r e p a p u l a r , a n d h a v e a yellowish color. 1° T h e endoscopic f e a t u r e s we identified could not be c o r r e l a t e d w i t h t h e histopathologic findings, b u t t h e y a r e p r o b a b l y in some w a y r e l a t e d to t h e severe i n f l a m m a t o r y process. H o w e v e r , b e c a u s e effective t h e r a p y for cryptosporidial disease is lacking, we c a n n o t p r o v e definitively t h a t t h e identified endoscopic a b n o r m a l i t i e s w e r e c a u s e d b y cryptosporidiosis. O u r cases f u r t h e r e x t e n d t h e s p e c t r u m of endoscopic a b n o r m a l i t i e s c a u s e d b y opportunistic infections in p a t i e n t s w i t h A I D S a n d e m p h a s i z e s t h e n e e d for m u -
cosal biopsy of all endoscopic lesions in the a p p r o p r i ate clinical setting.
Gastric purpura: an unusual endoscopic feature in gastrointestinal hemorrhage
rhage, 2 b u t p u r p u r a in the s t o m a c h is r a r e l y s e e n d u r i n g endoscopy. We r e p o r t two cases of gastric purp u r a associated w i t h acute g a s t r o i n t e s t i n a l h e m o r rhage.
Ronald Hsu, MD Tedessa Desta, MD Joseph Leung, MD, FRCP Acute u p p e r g a s t r o i n t e s t i n a l h e m o r r h a g e is comm o n l y due to g a s t r o d u o d e n a l ulcers, varices, Mallory Weiss t e a r , congestive g a s t r o p a t h y , esophagitis, Dieulafoy's lesions, a n d a r t e r i o v e n o u s m a l f o r m a t i o n s . 1 V a r i o u s m u c o s a l f e a t u r e s such as petechiae, ecchymosis, erosions, a n d u l c e r a t i o n s h a v e b e e n described in p a t i e n t s w i t h a c u t e u p p e r g a s t r o i n t e s t i n a l h e m o r From the Division of Gastroenterology, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California. Reprint requests: Ronald Hsu, MD, Gastroenterology, 4301 & X Street, Professional Building Room 2040, University of California, Davis Medical Center, Sacramento, CA 95817. oo16-5107/97/45o6-o52755.o0 +0 GASTROINTESTINAL ENDOSCOPY Copyright © 1997 by the American Societyfor Gastrointestinal Endoscopy 37/4/81017
VOLUME 45, NO. 6, 1997
REFERENCES 1. Genta RM, Chappell CL, White AC Jr, Kimball KT, Goodgame RW. Duodenal morphology and intensity of infection in AIDSrelated intestinal cryptesporidiosis. Gastroenterology 1993; 105:1769-75. 2. Kotler DP, Francisco A, Clayton F, Scholes JV. Small intestinal injury and parasitic diseases in AIDS. Ann Intern Med 1990;113:444-9. 3. Papp JP Jr, De Young BR, Fromkes JJ. Endoscopic appearance of cryptosporidial duodenitis. Am J Gastroenterol 1996;91: 2235-6. 4. Dworkin B, Wormser GP, Rosenthal WS, Heier SK, Braunstein M, Weiss L, et al. Gastrointestinal manifestations of the acquired immunodeficiency syndrome. A review of 22 cases. Am J Gastroenterol 1985;80:774-8. 5. Connolly GM, Dryden MS, Shanson DC, Gazzard BG. Cryptosporidial diarrhoea in AIDS and its treatment. Gut 1988;29:593-7. 6. McGowan I, Hawkins AS, Weller IVD. The natural history of cryptesporidial diarrhoea in HIV-infected patients. AIDS 1993; 7:349-54. 7. Roberts WG, Green PH, Ma J, Carr M, Ginsberg AM. Prevalence of cryptosporidiosis in patients undergoing endoscopy: evidence for an asymptomatic carrier state. Am J Med 1989; 87:537-9. 8. Cersosimo E, Wilkowse CJ, Rosenblatt JE, Ludwig J. Isolated antral narrowing associated with gastrointestinal cryptospordiosis in acquired immunodeficiency syndrome. Mayo Clin Proc 1992;67:553-6. 9. Massimillo AJ, Chang J, Freedman L, Baxi R, Kanth N, Pellecchia C. Cryptosporidium gastropathy: presentation of a case and review of the literature. Dig Dis Sci 1995;40:186-90. 10. WilcoxCM. Duodenum and small bowel. In: WilcoxCM, editor. Atlas of clinical gastrointestinal endoscopy. Philadelphia: WB Saunders, 1995:194.
CASE REPORTS Case 1 An 87-year-old man presented to the emergency department. He had had a flu-like illness for a few days and had passed a cup of bright-red bloody emesis. He denied any abdominal pain. He had a remote history of peptic ulcer disease but was not on any maintenance therapy at presentation. There was no usage of aspirin or nonsteroidal antiinflammatory agent for at least 6 months prior to admission. He did not smoke or use alcohol. There was no history of liver disease. On admission, he was orthostatic and was noted to have multiple flat purpuric lesions on both legs. There were no signs of chronic liver disease such as spider angioma, hepatosplenomegaly, or jaundice. The abdomen was soft and nontender, and the rectal examination showed red-tinged stool. His blood tests revealed a very low platelet count of 5000 (normal: 130,000 to 400,000/ram3). The hemoglobin level was 6.7 (14 to 18 gm/dl), white blood cell count was 11,400 (4,800 to 10,800/ram3), INR was 1.03, partial thromGASTROINTESTINAL ENDOSCOPY 527