Plaque-like Lesions Research Articles

Mass-like Dieulafoy\u2019s lesion associated with advanced gastric cancer at the antrum of stomach: a case report and literature review

BackgroundDieulafoy’s lesion, also known as a caliber-persistent artery, is a shallow, small, and rare lesion that occurs along the lesser curvature of proximal stomach. It is rare for a Dieulafoy’s lesion to present as a mass-like lesion that coexists with gastric cancer. To our best knowledge, we report the first case and histopathological pictures of a mass-like Dieulafoy’s lesion coexisting with advanced gastric cancer in the antrum of the stomach.Case presentationA 57-year-old female presented with a 6-month history of intermittent epigastric dull pain and dyspepsia. Subsequent upper gastrointestinal endoscopy revealed a friable mass that was located between the distal antrum and the pyloric ring. Biopsy revealed it to be an intestinal type adenocarcinoma. Subtotal gastrectomy was performed after neoadjuvant chemotherapy. Grossly, a large irregular plaque-like tumor lesion was noted at the anterior wall of the distal antrum and pylorus ring near the lesser curvature, measuring 5.6 × 4.8 × 1.0 cm. Histopathological examination of the resected stomach revealed that the plaque-like lesion largely consisted of numerous abnormally large-caliber and tortuous arteries in the submucosa. The increased fibrosis of the submucosa resulted in the formation of elevated plaque. The intestinal type adenocarcinoma was noted to be largely confined to the mucosa layer, with focal submucosal and muscular propria involvement. The patient was discharged one week after the subtotal gastrectomy, and she was alive and well 17 months after discharge, with no major complications.ConclusionThis is the first case of a mass-like Dieulafoy’s lesion coexisting with advanced gastric cancer at the distal antrum area. This case highlights the possibility of life-threatening gastric bleeding after mucosal resection or biopsy that could be encountered by endoscopists.

Colonic Amyloidoma: A Rarely Encountered Finding

Amyloidosis is a systemic disease characterized by the extracellular deposition of abnormal protein fibrils throughout the body that disrupts normal tissue architecture and function. It can present in many different forms, but the most common form that affects the gastrointestinal tract (GIT) is amyloid light-chain (AL) amyloidosis. Although amyloid deposition in the GIT is not uncommon, less than 50% will develop GI symptoms including GI dysmotility, malabsorptive diarrhea, spontaneous hemorrhage, and pseudo-obstruction. Early diagnosis of AL amyloidosis is essential because most cases are diagnosed late and associated with a poor prognosis. If left untreated it can carry median 1-year mortality rate of approximately 50%. Identifying the classic findings of AL amyloidosis during endoscopy should prompt further evaluation for disease. Our patient is a 54-year-old man with a past medical history significant for AL amyloidosis diagnosed on renal biopsy, who presented with worsening hematochezia. He also reported recurrent abdominal pain, a 60-pound weight loss, chronic diarrhea, and recurrent syncope for the last 4 months. Hemoglobin was 8.4 g/dL on admission. Colonoscopy revealed multiple large and small hemorrhagic polypoid lesions. The largest lesion filled approximately 75% of the colon. Multiple blood clots were also identified, but no active bleeding was seen during endoscopy. Endoscopic biopsies were not pursued given significant bleeding risk and prior diagnosis of AL amyloidosis. AL amyloid deposition within the vascular walls of the GIT increases vessel fragility and can result in hemorrhage beneath the lamina propria, forming submucosal hematomas. During endoscopy, submucosal hematomas appear purple and have a polypoid appearance with a shelf-like base. Other common findings during endoscopy include: mucosal ulcerations, intestinal erosions, yellowish plaque-like infiltrative lesions, and thickened mucosal folds. Rarely, as evident in our case, patients may have tumor-forming deposits of amyloid called amyloidomas, which can be wrongly diagnosed as a primary or metastatic GI malignancy. Given the poor prognosis associated with AL amyloidosis, recognizing common endoscopic findings should prompt the endoscopist to maintain a high index of suspicion and diagnose amyloidosis to improve overall prognosis.Figure: Endoscopy Findings.

Cytomegalovirus infection masquerading as gastric carcinoma in an immune-compromised host

A 63-year-old man post-renal transplantation on immunosuppressants presented with reflux symptoms for one month. Significant medical history included a history of upper gastrointestinal bleeding, insulin-dependent diabetes mellitus and ischemic heart disease. Barium meal showed a large plaque-like lesion along greater curvature suspicious of malignancy. Gastroscopy revealed a large polyploidal gastric mass which was biopsied. Histological result showed numerous cytomegalovirus (CMV) viral inclusions within hyperplastic gastric mucosa without dysplasia or neoplasm. The findings were consistent with CMV gastric polyp. Following treatment with antiviral therapy and reduction in immunosuppressants, the CMV gastric polyp became smaller. This highlights the importance of considering CMV as a differential of gastric mass in an immunosuppressed host as treatment options varied between surgery and antiviral therapy.

Neuronal Apoptosis: Pathological Basis of Behavioral Dysfunctions Induced by Angiostrongylus cantonensis in Rodents Model.

Angiostrongylus cantonensis invades the central nervous system (CNS) of humans to induce eosinophilic meningitis and meningoencephalitis and leads to persistent headache, cognitive dysfunction, and ataxic gait. Infected mice (nonpermissive host), admittedly, suffer more serious pathological injuries than rats (permissive host). However, the pathological basis of these manifestations is incompletely elucidated. In this study, the behavioral test, histological and immunohistochemical techniques, and analysis of apoptotic gene expression, especially caspase-3, were conducted. The movement and motor coordination were investigated at week 2 post infection (PI) and week 3 PI in mice and rats, respectively. The cognitive impairs could be found in mice at week 2 PI but not in rats. The plaque-like lesion, perivascular cuffing of inflammatory cells, and dilated vessels within the cerebral cortex and hippocampus were more serious in mice than in rats at week 3 PI. Transcriptomic analysis showed activated extrinsic apoptotic pathway through increased expression of TNFR1 and caspase-8 in mice CNS. Immunohistochemical and double-labeling for NeuN and caspase-3 indicated the dramatically increased expression of caspase-3 in neuron of the cerebral cortex and hippocampus in mice but not in rats. Furthermore, western-blotting results showed high expression of cleaved caspase-3 proteins in mice but relatively low expression in rats. Thus, extrinsic apoptotic pathway participated in neuronal apoptosis might be the pathological basis of distinct behavioral dysfunctions in rodents with A. cantonensis infection. It provides the evidences of a primary molecular mechanism for the behavioral dysfunction and paves the ways to clinical diagnosis and therapy for A. cantonensis infection.

An open label, phase II trial of continuous low-irradiance photodynamic therapy (CLIPT) using verteporfin for the treatment of cutaneous breast cancer metastases.

TPS1121 Background: Cutaneous metastases occur in approximately 20% of patients (pts) with metastatic breast cancer (mBC) and can be highly symptomatic and distressing. Radiation is frequently offered, but progression often occurs quickly. Photodynamic therapy is a promising approach with encouraging results in small studies. Here we will evaluate a novel Continuous Low-Irradiance Photodynamic Therapy (CLIPT) system that emits 690nm LED via a handheld powerpack attached to a single-use sterile light patch to deliver a total energy level of 10J/cm2. Verteporfin (Visudyne) is a photosensitizer approved for ophthalmological use that when combined with CLIPT generates activated oxygen species which can destroy tumor cells with limited normal tissue reaction. Methods: This open label, phase 2 study will evaluate the efficacy and safety of CLIPT with verteporfin in 15 pts with cutaneous lesions from mBC. Pts will receive a single IV injection of verteporfin on day 1. The 9x9cm patch with an adhesive border is placed over the treatment site and attached to the CLIPT portable power pack. The pt turns the device on at home 6 hours after the verteprofin injection and it automatically turns off after 24 hours. The pt will remove the patch and return to clinic on day 3. The primary endpoint is objective response rate (RR) at 3 weeks following CLIPT using a modified RECIST which accounts for nodular or diffuse plaque-like lesions. Secondary endpoints include RR at 2, 8 and 12 weeks, toxicity, and quality of life (using FACT-B, a Participant Symptom Scale, and Brief Pain Inventory). Pts who derive clinical benefit may be retreated up to 3 times to the same or different region. Eligible pts will have: cutaneous metastases from mBC with measurable disease by protocol defined modified RECIST 1.1, ≥ 1 line of prior systemic or local therapy for mBC, ≥ 14 days from prior systemic therapy or 60 days from radiation to target lesion, and no expectation for systemic therapy for ≥ 14 days after CLIPT. RR will be reported with 95% CI. If ≥ 3 responses (RR ≥ 20%) are observed, the null hypothesis of RR ≤ 5% will be rejected. At the time of abstract submission, 1 patient has been accrued. Clinical trial information: NCT02939274.

Gut-associated Lymphoid Tissue (GALT) Carcinoma or Dome Carcinoma?

The vast majority of colorectal carcinomas (CRCs) evolve from mucosa not associated to lymphoid tissues aggregates via the adenoma-carcinoma sequence or via the serrated pathway. Rarely CRCs evolve from gut mucosa associated to lymphoid tissue (GALT). Based on the presence of a circumscribed elevation in the colorectal mucosa, GALT carcinomas are also referred to as dome carcinomas (DC). Descriptions of the surface mucosa covering 21 GALT-CRCs appearing in pathological reports were reviewed. Three of the 21 GALT-CRCs fulfilled the criteria of dome carcinoma. Of the remaining 18 GALT-CRCs, nine were described as polypoid lesions, five as plaque-like lesions, two as sessile elevated lesions or mass, one as ulcerated and one as histological finding. Hence, only 14.3% (n=3) of the 21 GALT-CRCs displayed a dome configuration, whereas the majority, 85.7% (n=18), exhibited structures other than dome shapes at gross or at histologic examination. It becomes apparent that by using "dome" in addressing carcinomas in the colorectal mucosa, many cases of GALT carcinomas might be overlooked. Another drawback of using the "dome" nomenclature is that dome-like outlines may be detected in small metastatic tumors in the submucosa or in small colorectal carcinomas not arising from GALT mucosa. Instead, by using "GALT carcinoma", that is the histologic diagnosis in addressing these neoplasias, all cases of GALT-CRCs will be included.

False Positive Duodenal Aspergillosis

Introduction: Invasive aspergillosis has been predominantly reported in immunocompromised patients. Of those there have only been several case reports of duodenal aspergillosis. However, in immune competent patients false positive aspergillus can be up to 50% particularly in patients on antibiotics or the presence of a different fungal infection. Case: 41-year-old male type 1 diabetic presented for outpatient esophagogastroduodenoscopy (EGD) due to abnormal computed tomography (CT). Several years prior he developed end stage renal disease due to sustained nephrotoxicity from amphotericin used to treat invasive aspergillosis secondary to immune suppression for islet cell transplant that eventually failed. Two weeks before he was admitted for epigastric pain. He had been taking aspirin 81 mg daily, but denied of any other non-steroidals. Also, he was being evaluated for revision of his arteriovenous fistula and received 150 mg prednisone prep. In the hospital he had undergone a CT of the abdomen without contrast that revealed moderate duodenitis. He was started on pantoprazole 40 mg with significant improvement in his symptoms and able to be discharged and scheduled for EGD. EGD revealed mild reflux disease with a 7-cm esophageal ulcer and mild patchy gastritis. No evidence of oral thrush or white mucosal plaque-like lesions noted within the esophagus. Biopsies were negative for H.pylori. Ulcerative duodenitis noted along the duodenal sweep. Biopsies revealed fungal hyphae with dichotomous branching via GMS and PAS stains suggesting aspergillus. The duodenal specimens were submitted for a second opinion. On second read, no significant tissue abnormality was noted. Detached squamous esophageal cells with fungal organisms consistent with candida esophagitis were seen. He was treated with fluconazole 100 mg for three weeks and pantoprazole 40 mg twice daily for an additional 8 weeks. EGD was repeated four months afterwards. Mild residual gastritis and duodenitis with no esophageal abnormalities seen. The duodenum was re-biopsied with no abnormalities. Discussion: His pretest probability for duodenal invasive aspergillosis was much higher than other immune competent patients. His atypical candida esophagitis most likely from his diabetes and recent steroid use lead to debris and resulted in a false positive reading. Thus, in immune-competent patients' findings of aspergillus should be highly questioned and other etiologies should be sought.

Polypoid urothelial tumor with inverted growth pattern in the renal pelvis: morphologic and molecular characteristics of a unique diagnostic entity

We report 13 cases of unique polypoid urothelial tumors with inverted growth pattern (PUTIPs) occurring in the proximal ureter and renal pelvis. We describe their morphologic features and further characterize them in regard to TERT promoter mutation status and microsatellite instability. Thirteen cases were identified in our consult archives from 1994 to present. Patients ranged in age from 52 to 83 years at the time of diagnosis (mean, 68.4 years). Grossly, lesions were described variously as pink-tan to white exophytic and friable lesions that were polypoid or pedunculated, located in the renal pelvis or proximal ureter. The masses ranged in size from 0.5 to 3.2 cm (mean, 1.6 cm). PUTIP is a polypoid, plaque-like lesion with features of the following: (1) inverted papillary urothelial neoplasm of low malignant potential, lacking an exophytic papillary component; (2) florid von Brunn nest proliferation within and radiating outward from the polypoid lesion; and (3) in some cases, an inverted papilloma with densely hyalinized collagenous stroma. All 4 PUTIPs with formalin-fixed, paraffin-embedded material available were positive for the TERT promoter mutation 228G>A by polymerase chain reaction and were microsatellite stable. Given that PUTIP clinically forms a tumor and is typically treated by nephroureterectomy, it is best regarded as a unique benign urothelial neoplasm that exclusively occurs in the renal pelvis/proximal ureter.

Retiform hemangioendothelioma: A rare case report

Retiform hemangioendothelioma is described as a rare variant of low-grade angiosarcoma, characterized by indolent clinical behavior and closely related to Dabska's tumor (DT). Clinically, patients often present with an asymptomatic slow-growing solitary nodular or plaque-like lesion with rare oral involvement. Here, we report a case of a 50-year-old female patient with retiform variety of hemangioendothelioma having maxillary localization with various clinical, radiographical, histopathological, and immunohistological features.

A Case of Solitary Nonvascularized Corneal Epithelial Dysplasia.

Background. Epithelial dysplasia is categorized as conjunctival/corneal intraepithelial neoplasia which is a precancerous lesion. The lesion is usually developed at the limbal region and grows towards central cornea in association with neovascularization into the lesion. Here, we report a case of isolated nonvascularized corneal epithelial dysplasia surrounded by normal corneal epithelium with immune histochemical finding of ocular surface tissues cytokeratins, for example, keratin 13 and keratin 12. Case Presentation. A 76-year-old man consulted us for visual disturbance with localized opacification of the corneal epithelium in his left eye. His visual acuity was 20/20 and 20/200 in his right and left eye, respectively. Slit lamp examination showed a whitish plaque-like lesion at the center of his left corneal epithelium. No vascular invasion to the lesion was found. The lesion was surgically removed and subjected to histopathological examination and diagnosed as epithelial dysplasia. Amyloidosis was excluded by direct fast scarlet 4BS (DFS) staining. Immunohistochemistry showed that the dysplastic epithelial cells express keratin 13 and vimentin, but not keratin 12, indicating that the neoplastic epithelial cells lacked corneal-type epithelium differentiation. Conclusions. The lesion was diagnosed as nonvascularized epithelial dysplasia of ocular surface. Etiology of the lesion is not known.

Progressive Disseminated Histoplasmosis and HIV/AIDS: a Dermatological Perspective

Progressive disseminated histoplasmosis (PDH) occurs as a result of internal spread of Histoplasma capsulatum from the lungs to organs rich in monocytes. This typically occurs in immunosuppressed patients, such as those with HIV/AIDS. Skin involvement is found in 10 % of all patients with PDH in the USA and in up to 25 % of those with AIDS. Crusted papular or plaque-like lesions are most common, with others being nodular, pustular, ulcerated, vegetative, acneiform, or wart-like. Lesions may be caused by the fungus itself or an immune response to the infection, such as erythema nodosum or erythema multiform. Histopathology demonstrates necrosis of the superficial dermal vessels. The differential diagnosis is broad and varies depending on the location and morphology of the lesion(s). Culture is the gold standard for diagnosis, and first-line treatment is amphotericin B for 1–2 weeks at a dose of 3 mg/kg/day.

Esophageal Mucosal Calcinosis Complicated by Upper GI Bleeding

Calcium deposition in the gastrointestinal tract in the setting of hypercalcemia, while rare, is most commonly localized to gastric mucosa. We present, to our knowledge, the first reported case of esophageal mucosal calcinosis. The patient is a 51 year old female with past medical history significant for chronic kidney disease secondary to lupus nephritis (on immunosuppression), coronary artery disease s/p stent placement, abdominal aortic aneurysm s/p repair, pericarditis, transfusion-related hepatitis C, recurrent deep venous thrombosis (DVT- on warfarin), primary hyperparathyroidism and osteoporosis who was initially admitted for acute right lower extremity (RLE) DVT and two large RLE hematomas despite a therapeutic INR, s/p IVC filter placement, as well as a lupus flare requiring rituximab therapy. During her hospital course, she developed epigastric pain, dysphagia (initially to solids and progressing to include liquids), and odynophagia. Physical exam was significant for epigastric tenderness. Pertinent labs included creatinine 2.14 mg/dL and calcium (corrected) 11.0 mg/dL. EGD revealed severe acute esophagitis with extensive necrotic exudate in the distal esophagus, characterized by white, plaque-like lesions, as well as erosive gastritis with minor oozing in the gastric antrum and body. In addition to a twice daily proton pump inhibitor (PPI), fluconazole was started for presumed candidal esophagitis. Pathology did not show evidence of fungal infection. Symptoms did not improve and repeat EGD was performed, demonstrating a white, circumferential, plaque-like lesion with areas of ulceration, necrotic exudates, inflammatory granulation tissue and focal small calcific deposits. Pertinent labs included phosphorous 3.3 mg/dL, intact PTH 187 pg/mL, Vitamin D 25-OH 14. Fluconazole was discontinued. A few days later, the patient had massive hematemesis and rectal bleeding with hemoglobin 4.1 g/dL, tachycardia, and hypotension in the setting of a supratherapeutic INR. Emergent EGD revealed active arterial bleeding in the distal esophagus, stopped with epinephrine injection and two hemoclips. Interventional radiology then embolized a left gastric artery branch supplying the corresponding area of bleeding. Neck imaging failed to show evidence of a parathyroid adenoma. The patient had no further bleeding, her symptoms improved on the PPI and she was discharged home on calcium and vitamin D supplementation. She planned to follow-up with endocrine surgery for parathyroidectomy evaluation. This is a unique case of hypercalcemia from untreated primary hyperparathyroidism causing esophageal calcium deposition, ultimately leading to inflammation, necrosis, and bleeding.Figure 1Figure 2

Optical Coherence Tomography Angiography and En Face Optical Coherence Tomography Features of Paracentral Acute Middle Maculopathy

To characterize the optical coherence tomography (OCT) angiography, en face OCT, and microperimetry features of paracentral acute middle maculopathy in both the acute phase and after resolution, and to propose a classification of distinct subtypes of this entity. Retrospective observational case series. Clinical histories, high-resolution digital color imaging, spectral-domain OCT images, fluorescein angiography, OCT angiography images, and en face OCT images of 16 patients with paracentral acute middle maculopathy were evaluated. Microperimetry was available in 6 patients. The most common referring diagnoses were isolated branch retinal arterial occlusion (5/16), combined central retinal vein and cilioretinal artery occlusion (4/16), and isolated central retinal vein occlusion (4/16). All patients demonstrated hyperreflective plaque-like lesions at the level of the inner nuclear layer on spectral-domain OCT, with no fluorescein angiographic correlate. OCT angiography demonstrated variable areas of capillary dropout within the superficial and deep retinal capillary plexi in these areas. En face OCT highlighted confluent areas of middle retina hyperreflectivity corresponding to these lesions. Three distinct en face OCT patterns were observed: arteriolar, fern-like, and globular. Microperimetry demonstrated relative scotomas mapping to the area of middle retinal hyperreflectivity seen on en face OCT. Paracentral acute middle maculopathy may be best evaluated with the use of en face OCT imaging, which corresponds to subjective and objective visual field defects. En face OCT appearance may be used to classify paracentral acute maculopathy into distinct subtypes.

Gastric Xanthoma: A Review of the Literature

Context: Xanthelasmas, also known as “xanthomas” and “lipid islands” are yellow plaque-like lesions characterized by the presence of lipid-containing histiocytes. Evidence Acquisition: Xanthomas are most commonly found in the stomach within the gastrointestinal tract, and at this location they are called Gastric Xanthoma (GX). Clinical significance of GX is still unknown. It has been suggested that GX could be related to gastric injury. Here we reviewed five decades of studies on GX in the literature. Results: Since, GXs was reported to be associated with potentially serious conditions of the stomach, the whole gastric mucosa should be examined carefully and biopsy should be taken from the lesion during the upper gastrointestinal endoscopy for diagnosis and rulling out gastric malignity. Conclusions: Gastric xanthomas should not be ignored and concomitant conditions should be treated.

Diagnostic value and safety of medical thoracoscopy in tuberculous pleural effusion

BackgroundDifferentiating tuberculous pleural effusion from other lymphocytic pleural effusions is often challenging. This retrospective study aimed to assess the efficacy and safety of medical thoracoscopy in patients with suspected tuberculous pleural effusion. MethodsBetween July 2005 and June 2014, patients with pleural effusions of unknown etiologies underwent medical thoracoscopy in our institute after less invasive means of diagnosis had failed. Demographic, radiographic, procedural, and histological data of patients with tuberculous pleural effusion were analyzed. ResultsDuring this 9-year study, 333 of 833 patients with pleural effusion were confirmed to have tuberculous pleurisy. Under thoracoscopy, we observed pleural nodules in 69.4%, pleural adhesion in 66.7%, hyperemia in 60.7%, plaque-like lesions in 6.0%, ulceration in 1.5% of patients with tuberculous pleurisy. Pleural biopsy revealed the presence of Mycobacterium tuberculosis in the pleural tissue or/and demonstration of caseating granulomas in 330 (99.1%) patients. No serious adverse events were recorded, and the most common minor complication was transient chest pain (43.2%) from the indwelling chest tube. ConclusionsOur data showed that medical thoracoscopy is a simple procedure with high diagnostic yield and excellent safety for the diagnosis of tuberculous pleural effusion.

Lymphovascular invasion and nodal metastasis in intramucosal adenocarcinoma of the esophagus and esophagogastric junction.

To evaluate the tumor parameters predictive of lymphovascular invasion (LVI) and nodal metastases in intramucosal adenocarcinoma (IMAC) of the esophagus and esophagogastric junction. In all, 171 cases of IMAC from esophagectomy database (1986-2009) were reviewed. LVI was evaluated on HE and by immunohistochemistry stain for D2-40 (in selected cases). Univariate analysis was performed to identify predictors for LVI (in this cohort) and nodal metastasis (for pooled data from literature review). Altogether 150 IMAC were included in the study after histology review; 7 (4.7%) showed LVI and one (0.7%) had nodal metastasis. LVI-positive IMAC were thicker (tumor thickness 3.0 ± 2.8 mm vs 1.3 ± 1.2 mm, P = 0.01), and more likely to invade the outer muscularis mucosae (M3) (P = 0.004), be poorly differentiated (P < 0.001), and to show a nodular or plaque-like lesion (P = 0.04) compared with LVI-negative IMAC. Patients' age, gender, the frequency of tumor multifocality, ulceration and tumor size were not significantly different between these two groups. The pooled rates of LVI and nodal metastases in IMAC from five published studies and this cohort were 6.0% (range 2.9-16.7%) and 3.4% (range 0-10.0%), respectively. Pooled analysis of studies with histology review showed that LVI in IMAC was associated with a nodal metastases rate of 27.3%. For IMAC of the esophagus and esophagogastric junction, LVI is associated with tumor thickness, M3 invasion, poor differentiation and the presence of nodular or plaque-like lesion; by pooled analysis, it is associated with a risk of nodal metastasis of 27.3%.

Diagnostic challenges of single plaque-like lesion paucibacillary leprosy.

The diagnosis of single-lesion paucibacillary leprosy remains a challenge. Reviews by expert dermatopathologists and quantitative polymerase chain reaction (qPCR) results obtained from 66 single-plaque biopsy samples were compared. Histological findings were graded as high (HP), medium (MP) or low (LP) probability of leprosy or other dermatopathy (OD). Mycobacterium leprae-specific genes were detected using qPCR. The biopsies of 47 out of 57 clinically diagnosed patients who received multidrug therapy were classified as HP/MP, eight of which were qPCR negative. In the LP/OD (n = 19), two out of eight untreated patients showed positive qPCR results. In the absence of typical histopathological features, qPCR may be utilised to aid in final patient diagnosis, thus reducing overtreatment and delay in diagnosis.

Metastatic Sarcoidosis of Terminal Ileum and Colon: Very Rare, but Important to Differentiate From Crohn’s Disease

Introduction: Sarcoidosis prevalence is reported to be 1-40 per 100,000 in the United States, but intestinal tract involvement is only 3.4% of that, with small bowel involvement considered to be the rarest. For Crohn’s disease, terminal ileum is the most common site, whereas for sarcoidosis, it is the least likely site in intestinal tract. A 66-year-old white male with history of hypertension, remote pulmonary sarcoidosis for 8 years came with complaint of increasing frequency of bowel movements for the past 2 months. Patient denied any other complaints. He was on amlodipine and tamsulosin. He had a 10-pack-year smoking history. Chest x-ray showed resolution of lymphadenopathy seen 8 years ago. CT scan of the abdomen showed small pulmonary nodules and mild splenomegaly. WBC count was 3900/uL, absolute neutrophil count was 3100/uL, with hemoglobin 13 g/dL, MCV 87.4 fL, calcium 8.7 mg/dL with normal chemistry and liver function tests. Outpatient colonoscopy showed 2 mm yellowish plaque-like lesions in colon and thickened folds in terminal ileum. Biopsy report showed multiple non-caseating granulomas involving the lamina propria and the submucosal tissue in both the colon and terminal ileum. Special stains for fungi and acid fast bacilli were negative. A diagnosis was made of small and large bowel sarcoidosis. Usually, treatment is indicated when organ function is impaired. It is not clear whether to treat asymptomatic gastrointestinal sarcoidosis or not. We decided not to treat the patient and follow up very closely. Sarcoidosis can mimic Crohn’s disease because of its non-caseating granulomatous pattern, but diagnosis is made based upon compatible history, demonstration of granulomas in at least 2 different organs, negative staining and culture for acid fast bacilli and fungi, absence of occupational or domestic exposure to toxins, and lack of drug induced disease. On biopsy, it can be differentiated by presence of Schaumann bodies, prominent intramucosal rather than sparse submucosal granumolas, lack of mucosal architectural distortion, acute inflammation, and lack of fistulas. In a very difficult case, ACE level can be really helpful too.Figure 1: Transverse colon sarcoidosis.

Factors influencing survivorship of rehabilitating green sea turtles (Chelonia mydas) with fibropapillomatosis.

Marine turtle fibropapillomatosis (FP) is a debilitating, infectious neoplastic disease that has reached epizootic proportions in several tropical and subtropical populations of green turtles (Chelonia mydas). FP represents an important health concern in sea turtle rehabilitation facilities. The objectives of this study were to describe the observed epidemiology, biology, and survival rates of turtles affected by FP (FP+ turtles) in a rehabilitation environment; to evaluate clinical parameters as predictors of survival in affected rehabilitating turtles; and to provide information about case progression scenarios and potential outcomes for FP+ sea turtle patients. A retrospective case series analysis was performed using the medical records of the Georgia Sea Turtle Center (GSTC), Jekyll Island, Georgia, USA, during 2009-2013. Information evaluated included signalment, morphometrics, presenting complaint, time to FP onset, tumor score (0-3), co-morbid conditions, diagnostic test results, therapeutic interventions, and case outcomes. Overall, FP was present in 27/362 (7.5%) of all sea turtles admitted to the GSTC for rehabilitation, either upon admittance or during their rehabilitation. Of these, 25 were green and 2 were Kemp's ridley turtles. Of 10 turtles that had only plaque-like FP lesions, 60% had natural tumor regression, all were released, and they were significantly more likely to survive than those with classic FP (P = 0.02 [0.27-0.75, 95% CI]). Turtles without ocular FP were eight times more likely to survive than those with ocular FP (odds ratio = 8.75, P = 0.032 [1.21-63.43, 95% CI]). Laser-mediated tumor removal surgery is the treatment of choice for FP+ patients at the GSTC; number of surgeries was not significantly related to case outcome.

Keloidal plaque in a patient with pulmonary tuberculosis: A rare morphological variant of tuberculosis verrucosa cutis

Tuberculosis verrucosa cutis (TVC), also known as warty tuberculosis, anatomist’s wart or prosector’s wart is characterized by the presence of verrucous plaque-like lesions, resulting from direct inoculation of the causative organism into the skin of a previously infected patient. A 59-year-old man presented with a hyperpigmented plaque on the chest wall which closely mimicked a keloid. He was a case of sputum-positive pulmonary tuberculosis and had repeatedly been applying early morning saliva on the lesion as a part of the indigenous practices for quick healing. There was further progression of the lesion with discharge from several sites. A smear for acid fast bacilli was positive from the discharge and growth on Lowenstein Jensen medium revealed growth of Mycobacterium tuberculosis. Biopsy was compatible with TVC and the patient was started on 6months anti-tubercular therapy. However, the plaque continued to persist with continuing discharge from multiple openings which necessitated surgical intervention, finally leading to near complete resolution of the plaque of TVC.