Abstract
We describe the case of a 70-year-old man with diabetic nephropathy undergoing hemodialysis. Four years following hemodialysis, he started taking lanthanum carbonate 1500 mg/day and lansoprazole 30 mg/day. Nine years following hemodialysis, he underwent screening esophagogastroduodenoscopy, which demonstrated the presence of the whitish cobblestone-like mucosa in the gastric corpus and multiple reddish depressed lesions with annular whitish mucosa in the antrum. With magnified narrow-band imaging endoscopy, a yellowish–white substance was observed in the villous structure, and subepithelial vessels were observed on the yellowish–white substance. Biopsies were taken from the whitish cobblestone-like mucosa of the upper corpus, a reddish depressed part of the antrum. Histologically, aggregates of cells containing amphophilic fine granular material were found in the mucosal interstitium. These cells stained positive for CD68 and were identified as histiocytes. Since he had been taking lanthanum carbonate for 5 years, we considered the possibility of histiocyte-mediated phagocytosis of lanthanum. Digital mapping via scanning electron microscopy with energy-dispersive X-ray spectrometry showed the presence of lanthanum and phosphorus in the interstitium and cytoplasm of histiocytes. The white, rough mucosa in the gastric body appeared 6 months following the commencement of lanthanum administration and still exists 3 years and 5 months after discontinuation of lanthanum.
Highlights
Lanthanum carbonate is a powerful phosphate-binding agent used to treat hyperphosphatemia in patients with chronic renal failure
Lanthanum deposition in the gastric mucosa was first demonstrated by Makino et al in 2015 [2]
Iwamuro et al reported that gastric mucosa with annular whitish mucosa, diffuse whitish mucosa, and whitish spots visible by endoscopy may be characteristic clinical features of lanthanum deposition [14, 16, 17]
Summary
Lanthanum carbonate is a powerful phosphate-binding agent used to treat hyperphosphatemia in patients with chronic renal failure. Serum Helicobacter pylori antibody levels were found to be negative (8.7 IU/ ml) (Table 1) He underwent screening esophagogastroduodenoscopy (EGD), which revealed whitish cobblestone-like mucosa [18, 19] in the gastric corpus (Fig. 1a) and depressed red lesions surrounded by annular whitish mucosa in the antrum (Fig. 1b). Aggregates of cells containing amphophilic fine granular material together with coarser brown to deep purple material were observed in the mucosal interstitium of the lamina propria at all biopsy sites by hematoxylin–eosin staining (Fig. 2a). Green and red indicated the presence of lanthanum and phosphorus, respectively, and brown spots formed in the presence of a lanthanum and phosphorus complex Both lanthanum and phosphorus were primarily found in histiocytes, with partial deposition in the interstitium (Fig. 3a–c). Three years and 5 months after discontinuation of lanthanum, whitish rough mucosa and depressed lesions surrounded by annular whitish mucosa improved a little (Fig. 4a, b), and the number of histiocytes has decreased (Fig. 5)
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