Multiple Deep Ulcers Research Articles

Ulcerative Enteritis-Like Disease Associated with Clostridium perfringens Type A in Bobwhite Quail (Colinus virginianus)

Ulcerative enteritis-like disease due to Clostridium perfringens type A was attributed as the cause of mortality in excess of 50% in a flock of 1000, 10-to-16-wk-old bobwhite quail (Colinus virginianus). Clinical signs in these birds ranged from sudden death to listlessness, depression, watery white droppings, ruffled feathers, loss of weight, and death in a few days. Necropsy of 30 birds revealed multiple deep ulcers of the mucosa throughout the small intestine and ceca, some with perforation and subsequent coelomitis (peritonitis). The livers in some birds contained white foci of necrosis, and many birds had enlarged and congested spleens. Microscopic lesions included multifocal severe fibrinosuppurative ulcerative enteritis associated with large numbers of rod-shaped gram-positive bacteria, and necrotizing hepatitis with or without rod-shaped bacteria. Anaerobic culturing of the intestine and liver yielded pure cultures of C. perfringens. The C perfringens isolates were of genotype A and were polymerase chain reaction-positive for alpha toxin and for cpb2, the structural gene for beta2 toxin. Repeated attempts to isolate C colinum by using a specialized medium containing 8% horse plasma were not fruitful, suggesting that the enteritis and hepatitis in these birds were produced by C pefringens. Retrospective examination of records of quail submissions to the California Animal Health and Food Safety Laboratory System over 16 yr revealed at least nine quail submissions in which isolation of C. perfringens from the liver, intestine, or both was associated with ulcerative enteritis and hepatitis in quail. This is the first description of ulcerative enteritis-like disease in quail associated with C perfringens. Final conclusions await experimental reproduction of the disease.

Doxycycline-induced ulceration mimicking esophageal cancer

IntroductionDoxycycline-induced esophageal ulcer patients are mostly young persons with no history of esophageal dysfunction. Heartburn, midsternal pain and dysphagia are the most common symptoms. It has generally a benign course. The present case is the first report of doxycycline-induced extensive ulcerations, mimicking esophageal cancer in two esophageal segments alongside, in the literature.Case presentationThis report describes a 16-year-old Caucasian girl who, while taking doxycycline capsules100 mg twice a day for acne vulgaris for 3 months, developed these symptoms. An upper endoscopy revealed multiple circumferential deep ulcerations surrounding fragile, irregular, hyperemic and hypertrophic mucosa at the level of the mid-esophagus and concomitantly in the lower esophageal sphincter. The lesions were biopsied to exclude esophageal carcinoma because of the suspicious appearance in the endoscopic examination. The histopathological examination, haematoxylin and eosin stained sections showed ulceration with a mixed inflammatory infiltrate. Doxycycline was discontinued and she was given sucralfate 1 g qid and omeprazole 20 mg bid orally. All symptoms of the patient were resolved on the third day of the treatment. After 4 weeks of the therapy, an upper endoscopic control examination demonstrated normal findings.ConclusionThe present case has been an uncommon presentation of doxycycline-induced extensive ulcerations, mimicking esophageal cancer in two esophageal segments, concomitantly. Even the lesions were biopsied to exclude esophageal carcinoma. A modification on the behavior of taking drugs can prevent these unpleasant complications.

A “Case” of Granuloma

Purpose: Case Presentation: A 22 year old Vietnamese immigrant in Canada for 16 years presented with a 5 month history of abdominal pain, weight loss and diarrhea. History was negative for medical problems, medication and drug use, smoking, alcohol, gastrointestinal bleeding, constitutional symptoms, infectious contacts, recent travel and extraintestinal manifestations of inflammatory bowel disease (IBD). Family history was negative for tuberculosis, IBD and colon cancer. Physical exam showed a pale, cachectic, afebrile, hypotensive (88/54) man with no postural drop. There was mild left lower quadrant tenderness and no lymphadenopathy. Lab investigations revealed hemoglobin 117 g/L, white blood cell count 20.6 × 109/L, neutrophil count 16.9 × 10∧9/L, mean corpuscular volume 79.1 fL and serum albumin 29 g/L. Remaining blood tests including electrolytes, creatinine, liver enzymes, amylase and TSH were within normal limits. Serum endomysial antibody and stool testing were negative. Colonoscopy showed a fistulous opening at the base of the cecum, marked mucosal nodularity with multiple pseudopolyps, deep ulcers and areas of denudation in the cecum, ascending and mid-transverse colon. Corticosteroid therapy was deferred due to possibility of tuberculosis. Intestinal biopsies showed moderate acid-fast bacillus with necrotizing granulomas. Nucleic acid amplification test was positive for Mycobacterium tuberculosis complex. The patient's gastrointestinal symptoms improved with antituberculous treatment and he made a full recovery. Discussion: Our case illustrates three important principles in the diagnosis and treatment of gastrointestinal tuberculosis (GI TB). First, tuberculosis infection should be considered in patients with clinical, endoscopic, radiological and histopathological features of Crohn's disease, especially where there is a predominance of ileal and cecal involvement. Immigration from a country with known endemic tuberculosis is an important risk factor, even if immigration is a remote event. Nonspecific symptoms of GI TB include fever, night sweats, weight loss, abdominal pain and diarrhea. Diagnosis of GI TB is based on detection of acid-fast bacilli in tissue or stool. Second, it is important to exclude the possibility of tuberculosis before the commencement of corticosteroid therapy, often used in the treatment of IBD, since corticosteroid therapy will increase morbidity of the patient with GI TB. Third, treatment of GI TB is primarily medical and although complications such as fistula formation, perforation and hemorrhage may require surgery, it is possible to treat gastrointestinal fistulae due to tuberculosis successfully with medical therapy alone.

A fatal case of Lucio phenomenon from India

A 65-year-old man presented with cutaneous ulcerations involving the legs, hands, abdomen, buttocks, and pinna, along with fever, arthralgia, and anorexia for the prior 10 days. On cutaneous examination, dark, irregular-shaped bizarre erythematous purpuric spots and angulated ulcers were seen over bilateral, upper extremities and trunk including dorsum of hands, finger tips and the pinnae of both ears. Most striking were the presence of multiple deep ulcers covered with a blackish eschar and in some areas yellow slough eroding the subcutaneous tissue with ragged margins. These ulcers were distributed symmetrically over the thighs, lower legs and gluteal region. Slit-skin smear examination revealed a bacterial index (BI) of 6+ with globi from earlobes, ulcers 3+, eyebrows 3+ and normal skin 2+ and morphologically showed mainly solid (20-30%), fragmented (60-70%) and granular (5-10%) acid-fast bacilli. Biopsy from the ulcer margin revealed an ulcerated epidermis and dermis. The dermis had infiltrate of foamy macrophages, and evidence of ischemic necrotizing vasculitis, with fibrinoid necrosis and new vessel formation. There was presence of clumps of acid-fast bacilli (AFB) within macrophages, periadnexally, perivascularly, and also within endothelial cells. These clinical and histopathological features helped us to arrive at the diagnosis of Lucio phenomenon in an untreated case of Lucio leprosy which is rarely reported from areas other than Mexico.

Essential Type II Mixed Cryoglobulinemia Causing Pyoderma Gangrenosum–Like Ulcers

A 47-year-old, otherwise healthy woman presented with multiple deep ulcers located primarily on her lower extremities that presented 6 days ago as blisters. A biopsy revealed livedoid vasculopathy, without any evidence of vasculitis. Extensive laboratory workup was positive only for type II cryoglobulins.

A case of cytomegalovirus-associated multiple gastric ulcers in ulcerative colitis

Dear Editor, Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) that affects the colon to variable extents. Extracolonic manifestations like peripheral arthropathy, erythema nodosum, episcleritis, pyoderma gangrenosum, and anterior uveitis are often observed in UC patients. However, in contrast to Crohn’s disease, which can involve the whole gastrointestinal tract, UC is known not to affect other hollow visci, except the colon. We present a case of multiple, deep, and excavating gastric ulcerations mimicking ulcers in active UC lesions. The gastric ulcers healed after discontinuing immunosuppressive therapy, and cytomegalovirus (CMV) was found in gastric and colonic tissues at later pathologic review. A 50-year-old woman visited our hospital complaining of abdominal pain and hematochezia. She had been diagnosed with ulcerative proctitis some 4 years previously and treated with oral and rectal aminosalicylates and rectal budesonide. Because of aggravated abdominal pain and hematochezia, she visited our emergency unit and was admitted. Sigmoidoscopic findings and pathologic examination of rectal biopsy specimens were consistent with active stage of chronic UC. She was administered with intravenous glucocorticoid with central venous hyperalimentation, intrarectal aminosalicylates, and glucocorticoid. On the 14th day in the hospital, she complained of epigastric discomfort, and subsequent esophagogastroduodenoscopy (EGD) showed multiple shallow and deep ulcerations with erosions affecting the whole stomach. A rapid urease test and histologic examination revealed neither the presence of Helicobacter pylori nor the evidence of malignancy. Under the impression of acute gastric mucosal lesion (AGML), intravenous proton pump inhibitor (PPI) and oral antacid were started. On the 17th day in the hospital, the computed tomography performed due to a localized sustained pain in the right lower quadrant abdomen suggested microperforation of the right-side colon. Because the patient rejected surgical treatment, intravenous broad-spectrum antimicrobials were started. On the 28th day in the hospital, the second EGD showed multiple gastric ulcers with increased diameters, and because PPI had been administered for only 2 weeks, treatment was continued. However, on the 30th day in the hospital, an acute ischemic cerebral infarction developed in the frontal lobe, and 14 days later, a larger infarction developed in the left parietal lobe. To prevent further infarction-associated damage, anticoagulation therapy was started, but due to aggravated hematochezia, anticoagulation was stopped, and anti-platelet treatment was started. On the 42nd and 63rd days in the hospital, the third and fourth EGDs showed increased numbers of multiple gastric ulcers with more increased diameters together with mucosal bridging folds. On the 54th day in the hospital, the second sigmoidoscopy showed active ulcerations, and intravenous ganciclovir was started because superimposed CMV infecInt J Colorectal Dis (2007) 22:1419–1420 DOI 10.1007/s00384-006-0230-6

Authors' Response to Letter

Authors' Response to Letter

Myocarditis Associated with Campylobacter jejuni Infection

An increasing number of reported cases suggest that Campylobacter jejuni (C. jejuni) has a wide pathogenic spectrum of extra-intestinal complications: Guillan Barré Syndrome, reactive arthritis and uveitis. We would like to present a case of myocarditis associated with C. jejuni enterocolitis. Case report: A previously healthy 21 year old Caucasian male presented two weeks after a trip to Corsica with fever and profuse diarrhea, with intermittent blood. Two days later, patient developed shortness of breath and chest pain. Patient had no prior surgeries. The physical exam was unremarkable, with the exception of tachycardia. Chest X-ray revealed an enlarged heart, and ECG demonstrated non-specific T-wave abnormalities. Echocardiogram demonstrated normal wall motion. WBC, ESR and Urine Toxicology were normal. Creatinine kinase and troponin were significantly elevated. The initial stool, blood and urine bacterial cultures as well as stool ova and parasites and viral cultures did not reveal any pathogens. Viral serologies were also negative. Patient was given a diagnosis of myocarditis and was treated supportively. Due to the unresolving diarrhea, colonoscopy was performed. The colonoscopy revealed erythematous, friable mucosa with multiple deep ulcers in the sigmoid colon (Figure 1). The pathology specimen revealed acute colitis with cryptitis and crypt abcesses. Stool culture of an aspirate obtained during colonoscopy revealed C.jeuni. Within one week of hospitalization patient improved. At 30 days follow up, the patient was symptom free, without further diarrhea or chest pain. Review of the literature reveals 14 case reports worldwide of myocarditis associated with C jejuni infection. The pathogenesis is unknown; however, it has been suggested that myocarditis develops either as a result of bacteremia or as a result of a secondary immune reaction. Myocarditis can present as sequelae of C jejuni infection. C jejuni should be considered as a culprit whenever there is a presentation of diarrhea in conjunction with myocarditis-like symptoms. [figure1]Figure

Infliximab as First‐Line Therapy in Severe Pediatric Crohn Disease

Infliximab as First‐Line Therapy in Severe Pediatric Crohn Disease

Intestinal tuberculosis with abdominal complications: radiologic and pathologic features.

To investigate radiologic and pathological features of intestinal tuberculosis with abdominal complications. Twenty-two patients with 23 surgically proven complications (nine intestinal obstructions, eight perforations, three fistulae, and three intestinal bleeds) were analyzed. Medical records, radiologic studies, and pathologic examinations were reviewed with special emphasis on searching for the common features in each group of complication. The most important single feature in seven of the nine patients with intestinal obstruction was the presence of stricture. In the remaining two patients, bowel adhesion was a primary cause of obstruction. In eight patients with intestinal perforation, both obstruction and ulcerations in the dilated proximal loop were the important features in six, and multiple deep ulcerations without obstruction was a primary cause in the remaining two. The common features in three patients with fistulae were focal or multiple strictures, severe adhesions, and fibrotic bowel wall. Intestinal bleeding originated from diffuse mucosal ulcerations. The abdominal complications occurred during antituberculous therapy in 10 of the 22 patients. Understanding the radiologic and pathologic features of intestinal tuberculosis with complications help in making an appropriate clinical decision for the treatment strategy. Close observation is necessary, especially in those patients who are acutely ill during antituberculous medical therapy. Enteritis-Intestines, diseases-Intestines, infection-Intestines, perforation-Intestines, stenosis or obstruction.

THE ROLE OF ENDOSCOPY IN DIAGNOSIS OF LYMPHOPROLIFERATIVE DISORDER (LPD) IN THE GASTROINTESTINAL TRACT (GI) OF CHILDREN AFTER LIVER TRANSPLANTATION(LTx)

156 During the last 14 years 342 children underwent liver transplant (LTx) at UCLA Medical Center. Twenty nine patients (8.5%) developed lymphoproliferative disorder (LPD). Ten (34.5%) had gastrointestinal involvement. Eight had polyclonal and two monoclonal LPD. FK506 has been used in 9 patients: in 5 it was used as an initial immunosuppressive agent, 4 others were changed to it for chronic rejection after cyclosporine failed to prevent rejection. These 4 also received OKT3. The presenting GI symptoms of LPD were: GI bleeding (5), abdominal pain (5), diarrhea (5), vomiting and dehydration (2), mouth sores(1). All were associated with two or more weeks of fever. The earliest symptoms of LPD occurred two months post-LTx. All 10 had abdominal CT which was suggestive for GI involvement in 3 (27%). Upper and lower endoscopy was done in 7. In all the esophagus was normal. Gastric involvement was diagnosed in 3 children. Two had multiple deep ulcers throughout the stomach. Endoscopically the duodenum appeared normal in all 7. There were no false positives but one false negative endoscopic diagnosis. The proximal jejunum was examined in 2 children. Endoscopic findings were multiple erosions in one patient and white patches of mucosa in the other. Retrograde ileoscopy was performed in 3. All 3 had mucosal lesions: multiple ulcers (1), white patches (1) and erosions (1). Colonic involvement was diagnosed in 6: multiple ulcers (2), patchy erythema and thickening of the cecum (1) and loss of mucosal vascular pattern with spontaneous firability(3). Conclusion: Combined upper and lower endoscopy with the multiple biopsies is the best diagnostic approach for the evaluation of gastrointestinal involvement for LPD.

A CASE OF CROHN'S DISEASE WITH MULTIPLE FREE PERFORATIONS OF THE SMALL INTESTINE

An 18-year-old male patient was admitted to a hospital complaining of fever and abdominal pain in mid-May, 1993. On June 25, sudden abdominal pain occurred, and the abdominal X-ray examination revealed free air. We performed emergency surgery with a diagnosis of panperitonitis. At operation, many indurations which were thought to be ulcers and four perforations were found in the ileum. After deciding the incision line of the intestine under intraoperative endoscopy, two meters of ileum and ascending colon were resected, and an ileostomy was then constructed. After the operation this case was diagnosed as Crohn's disease, because multiple acute deep ulcers with granulomas were observed microscopically. The ileostomy was closed and an anastomosis between the ileum and the ascending colon was made under administration of salazosulfapyridine for six months. Reports of Crohn's disease with multiple free perforations of the small intestine are rare in the Japanese literature. Here, we present this case with a review of 7 other case reports.

Cytomegalovirus esophagitis in AIDS: radiographic features in 16 patients.

Cytomegalovirus is one of the more common opportunistic organisms implicated in the development of esophagitis in patients with AIDS. A review of the radiographic features of 16 proved cases of cytomegalovirus esophagitis showed a spectrum of abnormalities related to the severity of the inflammatory process. Seven patients had a mild form of esophagitis with segmental involvement characterized by granular mucosa, superficial erosions, and poorly defined, shallow ulcerations. Nine patients had more severe esophagitis with solitary or multiple deep ulcers and a background of normal mucosa. The deep ulcerations were oval in shape and varied in size. Some projected intraluminally and had a thin rim of radiolucency at the base. Short-term follow-up examinations showed progression of the disease in four patients, no change in one patient, and regression without specific therapy in one patient. Although these radiographic features are highly suggestive of cytomegalovirus esophagitis, the diagnosis requires histologic confirmation.

Massive Gastrointestinal Hemorrhage Cecal Ulcers and Salmonella Colitis

A 65-year-old man presented with massive lower gastrointestinal tract hemorrhage. Minimal changes were noted on sigmoidoscopy, no bleeding lesions were identified on arteriography or red blood cell scan, and barium enema examination demonstrated only diverticular disease and minimal cecal deformity, interpreted as secondary to a recent appendectomy. Colonoscopy demonstrated multiple deep cecal ulcers. These were presumed to be due to an infectious etiology, since the stools were culture-positive for Salmonella typhimurium. The hemorrhage stopped within 24 hours of treatment with Ampicillin, Flagyl, and Gentamicin. The patient has remained well over a 12-month follow-up period. Repeat colonoscopy demonstrated healing of the cecal ulcers and there was also clearing of the Salmonella from the stools. This case report serves to remind us of the different methods used to diagnose lower gastrointestinal tract hemorrhage, and the importance of considering infectious causes of colitis.