Shallow Ulcers Research Articles

Treatment of recurrent aphthous stomatitis by laser therapy: A systematic review of the literature.

Recurrent aphthous stomatitis (RAS) is defined as multifactor immunologic inflammatory lesions in the oral cavity, characterized by painful, recurrent single/multiple, shallow, round or ovoid ulcerations of mucosal tissues. To date, a considerable number of RAS treatment protocols have been suggested, but since the etiology of RAS is idiopathic, these treatment options have symptomatic rather than curative or preventive effect. Recently, it has been suggested that laser therapy could be successfully used as an efficient treatment approach in therapy of RAS. Therefore, the aim of this review was to estimate the effects of laser therapy in treatment of RAS analyzing results of clinical studies published in peer reviewed journals. The studies published until 31 December 2013 were obtained from the Medline/PubMed, Science Direct and Cochrane Library of the Cochrane Collaboration (CENTRAL) online databases, using following search terms and key words: "laser" AND "recurrent aphthous stomatitis", "laser" AND "aphthous", and "laser" AND "aphthae". In total 4 original research articles met the all required inclusion/exclusion criteria, and were used for this review. The main outcome measures assessed were: a reduction of pain associated with RAS and a reduction in episode duration (faster RAS healing). The assessed literature demonstrates the benefits of laser therapy mainly due to immediate analgesia and ability to speed up a RAS healing process. Even thoughthe assessed literature suggests beneficial outcomes of laser therapy in treatment of RAS, these results should be interpreted with caution. The issues related to the study designs and different sets of laser irradiation parameters of a limited number of available studies with the same treatment outcomes prevent us from making definite conclusions.

A Case of Varicella Zoster Hemorrhagic Gastritis

Introduction: Hemorrhagic gastritis secondary to Varicella zoster virus (VZV) is rarely identified in immunocompromised patients, and we report such a case from our experience. An 82-year-old female with chronic lymphoid leukemia receiving chemotherapy, presented with 1 week of anorexia, abdominal pain, nausea and vomiting. Lab evaluation was significant only for thrombocytopenia, and abdominal CT scan was unrevealing. Her symptoms persisted despite hydration and pain control, and on hospital day 5 she developed worsening thrombocytopenia with transaminemia and leukocytosis. Viral hepatitis panel including HSV, CMV and EBV was negative, as was an abdominal ultrasound with doppler. An upper endoscopy performed to evaluate her symptoms revealed small, hemorrhagic, irregular shallow ulcerations and erosions throughout the stomach (Figure 1A). A diffuse vesicular rash developed on hospital day 10, and acyclovir was initiated empirically. Multi-organ failure rapidly ensued, and care was withdrawn. The endoscopic biopsies later revealed epithelial hemorrhage, ischemia and nuclear viral inclusions with a strongly positive immunohistochemical stain for VZV, consistent with acute hemorrhagic gastritis due to VZV (Figure 1B). Viral swab of a skin lesion was positive for VZV by PCR.Figure 1: (A) Hemorrhagic, ecchymotic shallow ulcerations and erosions with exudate. (B) Immunohistochemical stain for VZV demonstrates diffuse and strong positivity within viral inclusions.Discussion: To our knowledge, this is one of a few cases of VZV hemorrhagic gastritis confirmed by endoscopic biopsy and PCR of cutaneous lesions. Reactivation of VZV is common in immunocompromised patients, usually presenting as a cutaneous eruption of vesicles. Rarely, visceral and gastric involvement can occur, usually concurrent with a hematologic malignancy and disseminated cutaneous involvement. The vesicular eruption can be absent initially and be first observed up to 10 days after abdominal symptoms develop. Presentation of visceral VZV is non-specific and may be characterized by nausea, vomiting, and abdominal pain with possible development of gastrointestinal hemorrhage, pancreatitis and hepatitis. While endoscopic evaluation is often unrevealing, gastrointestinal mucosal involvement can occur in the form of gastric ulcerations or punctate hemorrhages. Treatment is with antivirals. A high clinical suspicion is important to recognize this condition early in the proper clinical setting, as mortality rate can be 40-50%.

An Unusual Case of CMV Gastritis in a Healthy Adult

Case Report: A 24-year-old obese female presented with a 2-week history of abdominal pain, nausea, vomiting, and dark stools. Her past medical history was significant for menorrhagia and iron deficiency anemia. Her abdomen was soft, moderately tender with normal bowel sounds. Superficial lymph nodes, including cervical, axillary, and inguinal were not palpable. Lab results revealed hemoglobin of 7.8 g/dL, MCV of 75.8 fL, WBC of 5.38 k/uL with lymphocytes at 61%, and monocytes at 7%. CT of the abdomen revealed an enlarged spleen. Monospot test was negative. Screening for HSV, syphilis, parvovirus, ova, and parasites was unremarkable. Serology for HIV 1 and 2 was negative. Her CD4 count was 615 cells/uL, CD8 count was 727 cell/uL, and the CD4:CD8 ratio was 0.85. Serology for EBV was positive for IgG and IgM antibodies against viral capsid antigens and IgG antibodies against nuclear antigen and early antigen. An EGD was done, which revealed a normal esophagus, moderate gastritis with edematous gastric folds, many non-bleeding superficial gastric ulcers spread on the entire stomach, with the largest measuring 3 mm, and a normal duodenum (Figure 1). The biopsy of the lesion revealed scattered cells with characteristic CMV inclusion bodies, and immune-histochemical staining was positive for CMV and negative for H.pylori (Figures 2A, 2B). Culture of the gastric biopsy also yielded CMV. She was treated with ganciclovir and omeprazole. Follow-up 4 weeks later revealed complete resolution of her symptoms.Figure 1Figure 2Discussion: Primary CMV infection in normal hosts is aymptomatic, but can lead to a mononucleosislike syndrome and, rarely, severe organ specific complications. This case shows the occurrence of classical CMV gastritis lesions in a normal healthy and young host, and emphasizes the need to include CMV in the differential when multiple, shallow gastric ulcers are found on upper endoscopy, even in immunocompetent hosts.

Spontaneous multicentric myxoma of the dermal nerve sheaths in farmed European eels Anguilla anguilla.

This report describes a peripheral nerve sheath tumour in 8 European eels Anguilla anguilla L. from a fish farm located in Croatia. The newborn tissue appeared as smooth and soft skin nodules without pronounced colour change. Nodules were dome-shaped with a pale crater and were present on different body areas. In general, nodules were located as series of differently sized protrusions extending along the lateral line on both sides of the fish, as well as sensory canals on the head. Cut sections showed a homogeneous, pale white-grey texture. Histologically, the pathological tissue was located in the dermis, occasionally intruding into the hypodermis, and pushing as a space-occupying mass against the underlying muscle tissue without any evident boundaries. The pressure also caused changes in the overlying epidermis, such as atrophy, spongiosis and erosion. In some areas, the epidermis was 1 cell thick and club and goblet cells had completely disappeared. Ultimately, these changes resulted in shallow ulceration. Tumour tissue was characterized by a scant population of spindle or stellate cells, with oval, hyperchromatic nuclei and pale cytoplasm embedded in a copious myxoid matrix. Cells were arranged in fascicles and whorls, extending in a poorly defined manner among the dermal collagen bundles. Occasionally, adipose cells were also detected, mainly in the central portion of the bulges. Myxoid areas appeared rich in metachromatic and alcianophilic mucous ground substance. Reticular fibres and collagenous connective tissue were scarce. Immunohistochemistry (IHC) using antibodies against S-100 and glial fibrillary acidic protein caused a slight positive reaction in neoplastic dendritic cells. High magnification showed the immunostaining to be cytoplasmic in all tumour cells. IHC with anti-calretinin antibody gave only negative results. Macroscopic, histological, histochemical and immunohistochemical findings were consistent with a diagnosis of multicentric myxoma of the dermal nerve sheaths, a tumour not yet reported in fish.

A comparative study of vitamin D serum levels in patients with recurrent aphthous stomatitis

BackgroundRecurrent aphthous stomatitis (RAS) is characterized by recurrent, painful, shallow, round or oval oral ulcers surrounded by inflammatory halos. Aim of the workTo investigate the status of vitamin D in RAS patients and the relationship between vitamin D levels and the severity of RAS. Patients and methodsIn this cross sectional study 46 patients with idiopathic minor RAS (MIRAS), and 49 age and sex matched healthy controls were included. Patients with at least 3 minor aphthous oral ulcers in a year without any known cause for RAS were determined as idiopathic minor recurrent aphthous stomatitis. The severity of RAS was assessed by the number of oral aphthous ulcers in each attack and the frequency of attacks. 25-Hydroxy vitamin D [25(OH) D] levels were measured by the Enzyme-Linked Immunosorbent Assay (ELISA) method in patients and control groups. ResultsThe mean 25(OH) D level in the MIRAS group was lower than the control group (12.1±7.7ng/dl vs. 27.4±9.7ng/dl, p=0.0001). Insufficiency and deficiency of 25(OH) D in the recurrent aphthous stomatitis groups were more common than those in the control group (Vitamin D sufficient, Vitamin D insufficient and Vitamin D deficient (p<0.0001 for all the cases)). No correlation was found between the serum levels of 25(OH) D and the duration of RAS, the number of oral aphthous ulcers in each attack, and the frequency of attacks (p<0.05 for all the cases). ConclusionsOur study suggests that deficiency of vitamin D may be a trigger factor for RAS.

Do mast cells play a pathogenetic role in neurofibromatosis type 1 and ulcerative colitis?

Concurrent association of neurofibromatosis type I and ulcerative colitis has been reported in one clinical case (Tavakkoli et al., 2009). Although this association may represent a casual finding, a common pathophysiology is postulated. Mast cells have been implicated in the pathogenesis of both neurofibromatosis type 1 and ulcerative colitis (He, 2004; Yoshida et al., 2010). Mast cells are typically present in neurofibromas microenvironment where they appear to contribute to tumor initiation, progression and angiogenesis (Staser et al., 2010, 2013). Moreover, interaction of mast cells with nerves throughout the gastrointestinal tract has been correlated with progression and maintenance of ulcerative colitis (Stoyanova and Gulubova, 2002). We describe a 14year-old male with history of neurofibromatosis type 1 and new onset of ulcerative colitis diagnosed on clinical and histological findings. On gross examination the entire colonic mucosa appeared edematous showing a peculiar granular pattern, with focal erythema, shallow ulcers and multiple sessile polyps. Hematoxylin and eosin stained tissue biopsies from the colonic mucosa showed chronic inflammatory bowel disease, severe activity, consistent with chronic ulcerative colitis. Immunohistochemistry stain of the intestinal lesions revealed high expression of Neuron Specific Enolase (NSE) and S100 highlighting the presence of a Schwann cell component. In addition, c-kit/CD117 positive stain indicated a marked increase of mast cells in the lamina propria. This pattern of cellularity in the lamina propria showing increased mast cells and augmented Schwann cell component was absent in the colonic mucosa of a normal control or a patient with ulcerative colitis alone. Our observation supports the evidence of a pathogenetic role of the mast cell in ulcerative colitis associated with neurofibromatosis type 1. Further investigations are warranted to confirm the significance of this correlation as it may impact therapeutic approaches of these pathologies.

Hand-foot-mouth Disease: Outbreak in Shimla

Forty seven (27 males) patients of HFMD were registered in the dermatology outpatient department at a tertiary hospital, within a period of two months (July to August 2013). Thirty six (76.5%) patients were children below the age of five years (mean, 3.2 yrs); twenty five from a single kindergarten in the city. Five adults (age range 30 to 47 years), who were parents of affected children, were also registered. Skin lesions were grayishwhite vesicles, elliptical to round in shape and surrounded by an erythematous halo. Oral involvement was in the form of shallow and irregular ulcers with a yellowish-grey base and erythematous margins. Oral involvement and typical lesions on hands and feet were seen in all cases. A prodrome of mild to moderate fever, anorexia, malaise, dysphagia and arthralgia was seen in 24 (51%) cases (Fig. 1). Palms were found to be the most common (n=36, 76.6%) site of involvement followed by dorsa of hands (n=26, 53%), soles (n=15, 25%), elbows (n=14, 29.8%) and buttocks (n=5, 1.1%). The buccal mucosa was the most common site (n=39, 82.9%) of intraoral involvement followed by palate (n=20, 42.5%), tongue (n=11, 23.4%), gingiva (n=9, 19.1%) and lips (n=6, 1.3%). No complication was noted in any case. All were treated symptomatically and lesions subsided within about a week without any sequelae.

Successful treatment of myelodysplastic syndrome and Behcet colitis after allogeneic hematopoietic stem cell transplantation

Successful treatment of myelodysplastic syndrome and Behcet colitis after allogeneic hematopoietic stem cell transplantation

Percutaneous endoscopic gastrostomy tube migration as a cause of small bowel obstruction

Dear Editor: A 71-year-old man with profound mental retardation was admitted with recurrent coffee-ground emesis. His care facility reported that his long-term percutaneous endoscopic gastrostomy (PEG) tube was functioning normally and it was confirmed to freely flush saline. Examination showed a balloon-type replacement PEG tube that could be freely inserted and rotated, but only withdrawn to the 6 cm marking with traction. Our clinical suspicion was distal migration of the PEG tube and possible obstruction. A computed tomography (CT) scan with intravenous and enteric contrast through the tube was performed and noted the balloon in the distal duodenum without evidence of perforation (Fig. 1). Endoscopy revealed the PEG tube passing across the gastric lumen and through the pylorus with the balloon occluding the 3rd portion of the duodenum. After removal, a non-bleeding cratered ulcer with a visible vessel and shallow ulcerations on the contralateral wall were found (Fig. 2). Two hemostatic clips were placed across the visible vessel and a balloon-type

Oral mucosal ulceration caused by the topical application of a concentrated propolis extract.

Propolis is a resinous mixture that is collected by honey bees from tree buds, sap flow, and other botanical sources. Propolis has been extensively used in medicine, dentistry, and cosmetics; however, unwanted effects have been reported. This paper reports a case of oral mucosal burn in a 50-year-old patient, who used an overnight application of concentrated propolis to overcome a throbbing pain in the right upper posterior mucosa. The patient was otherwise healthy and was not receiving any medication. She presented with painful shallow multiple irregular ulcers measuring 0.3–1 cm in diameter that were located on the right buccal mucosa and hard palate mucosa, in addition to the gingival mucosa surrounding tooth 17. Propolis-induced oral mucosal burn was diagnosed. The ulcer cleared after the prescription of tetracycline mouthwash, accompanied with Doloneurobion. The patient was further treated with carbamazepine to address the persistent throbbing pain in the affected area, which was suspected to be trigeminal neuralgia. This report provides another alert to clinicians about the potential adverse effects of propolis use for the treatment of oral diseases, despite its natural origin.

An unusual gross appearance of vulval tuberculosis masquerading as tumor.

Tuberculosis of the vulva is very rare. It is found in about 0.2% of the cases of genital tract tuberculosis. It usually presents as small shallow ulcers and multiple sinus tracts or rarely as elephantiasis of vulva. Except for very rare cases of primary tuberculosis in the vulva, it is usually associated with tuberculosis elsewhere in the body leading to secondary tuberculosis. Here, we report a case of secondary vulval tuberculosis which presented as a vulval mass in a 40-year-old female patient. The rarity of this presentation in the female genital tract is emphasized.

Jejunal perforation secondary to jejunal heterotopic gastric mucosa – a case report

Jejunal heterotopic gastric mucosa is rare entity. Furthermore, perforated ulcer secondary to jejunal heterotopic gastric mucosa is extremely rare. A 51-year-old male presented with abrupt abdominal pain. At that time, he was taking medication for his pulmonary tuberculosis. He underwent laparotomy due to pneumoperitoneum. At laparotomy, a perforation site was found 100cm distal to the ligament of Treitz. On macroscopic examination, the mucosa showed an ill-defined shallow ulceration adjacent to the perforation site. Microscopic examinations revealed a perforated peptic ulcer with heterotopic gastric mucosa composed of foveolar epithelium and pyloric and fundic type glands.

A case of localized amyloid light-chain amyloidosis in the small intestine.

Amyloidosis is characterized by the abnormal deposition of extracellular amyloid fibrils. Cases involving amyloid light-chain amyloidosis in the small intestine have been reported infrequently in Korea. Here, we report a case of localized light chain protein amyloidosis in the small intestine. Esophagogastroduodenoscopy, push enteroscopy, and capsule endoscopy revealed submucosal tumor-like lesions, multiple shallow ulcers, and several erosions in the distal duodenum and jejunum. An endoscopic biopsy established the diagnosis of amyloidosis. In through an immunohistochemical analysis, the presence of lambda light chain protein was detected. The patient had no evidence of an underlying clonal plasma cell disorder or additional organ involvement. Therefore, we concluded that the patient had localized amyloidosis of the small intestine.

A Rare Cause of Diarrhea and Weight Loss

Purpose: A 70-year-old man presented with a five-month history of abdominal pain, low-grade fever, fatigue, anorexia, diarrhea and a 30-pound weight loss. The initial evaluation included EGD and ileocolonoscopy, with random biopsies showing an increase in colonic intraepithelial lymphocytes and mild plasmacytosis. An abdominal CAT scan showed two separate segments of small bowel circumferential thickening. Infectious etiologies were excluded and a presumptive diagnosis of Crohn's disease was rendered. He was empirically treated with steroids with partial improvement. Several weeks later, he presented with continued symptoms, as well as diffuse edema consistent with anasarca. A repeat evaluation was negative for celiac disease, stool culture, ova and parasite, C. difficile, mycobacterium tuberculosis, HIV, and fecal fat. Laboratory showed a hemoglobin 11.1 g/dL, platelet 131 X 10ˆ9/L, BUN 32.3 mg/dL, creatinine 1.2 mg/dL, albumin 1.9 g/dL, prealbumin 29.9 mg/dL, and increased serum-feces alpha-1 antitrypsin clearance 53 (<27). These findings suggested a protein-losing enteropathy, which prompted a deep enteroscopy. Retrograde deep enteroscopy showed diffuse edema, erythema and shallow ulcerations in the distal ileum up to 80 cm from the ileocecal valve. Terminal ileum histology showed a dense, small, mature-appearing lymphocytic infiltrate expanding the lamina propria, extending into the submucosa with blunted villi without significant intraepithelial lymphocytosis. The immunophenotype was positive for CD3, CD5, CD7, CD56 and T-cell gene rearrangement, and negative for CD4, CD8, and Tdt. Enteropathy-associated T-cell lymphoma (EATL) was diagnosed. The patient was started on cyclophosphamide, etoposide, vincristine and prednisone alternating with pralatrexate. Unfortunately, he developed bacteremia, septic shock and expired six weeks later. EATL is an uncommon gastrointestinal T cell lymphoma and is strongly associated with celiac disease. Patients typically present with abdominal pain, systemic B symptoms, fatigue or anorexia. The small intestine was the most commonly involved site at diagnosis (90%), followed by the large intestine (16%) with frequent involvement of mesenteric (35%) and para-aortic or iliac lymph nodes (11%). Clinical, radiologic and endoscopic manifestations of EATL can mimic Crohn's disease, as demonstrated in this case. The development of a protein-losing enteropathy in this case broadened the differential leading to the final diagnosis. Deep enteroscopy is an important endoscopic tool to obtain tissue for the proper diagnosis of EATL, especially when suggested by other imaging modalities, such as abdominal CT scan.

Epstein-Barr Virus-associated Gastric Lymphoepithelioma Like Carcinoma

Case Presentation: A 69-year-old female presented with a six-month history of intermittent epigastric pain associated with 15-pound weight loss. She denied any past medical or surgical history. Physical exam was benign but her lab results were significant for microcytic anemia. Computed tomography (CT) of the abdomen with oral contrast demonstrated thickening of the anterior and posterior walls of the body and antrum of the stomach. Upper endoscopy revealed a large, friable, ulcerated, malignant-appearing mass in the antrum. Biopsy indicated invasive gastric adenocarcinoma, poorly differentiated with ulceration. The patient underwent a subtotal distal gastrectomy with gastrojejunostomy, followed by radiation therapy. Pathologic findings of the resected stomach showed a well demarcated tumor with raised border and central shallow ulcer in the antrum extending to and involving the lesser curvature, partially involving but not obstructing the pylorus. Microscopically, an undifferentiated carcinoma with intense lymphoid infiltration, invading through muscularis propria and subserosal connective tissue was detected. The tumor cells were polygonal with pale eosinophilic cytoplasm. Carcinoma cells stained strongly positive for both EBV and cytokeratin. CD3 was positive, evenly distributed throughout the tumor with intimate contact with individual carcinoma cells. CD20 was positive, sparsely scattered within the tumor. Three out of 15 lymph nodes along the lesser curvature were positive for metastatic carcinoma with lymphovascular invasion. The case was diagnosed as a gastric lymphoepithelioma-like carcinoma and the pathologic staging was T3N2M0 or UICC/AJCC Stage IIIb. Surveillance endoscopy performed two months post gastrectomy revealed chronic gastritis; however, no tumor was detected. No positron emission tomography evidence of metastatic spread of tumor was observed. Discussion: Lymphoepithelioma-like carcinoma (LELC) is a descriptive term for poorly differentiated carcinoma accompanied by prominent infiltration of lymphocytes; notably seen in nasopharyngeal and gastric carcinomas. Lymphoepithelioma-like gastric carcinoma is a rare neoplasm of the stomach most often seen in males, with a better prognosis than conventional adenocarcinoma. More than 80% of gastric LELC have been found to be related to EBV infection. EBV associated LELC is associated with 4-16% of gastric adenomas, with variations across populations. Even rarer is EBV associated LELC with lymph node metastasis. Fortunately for our patient, surveillance endoscopy has been negative for malignancy, to date.

Primary Herpes Esophagitis in a Liver Transplant Recipient

Purpose: Herpes esophagitis is a common infection in immunocompromised patients. It is usually due to secondary reactivation, but it may also present as a primary infection. We present a case of primary infection of herpes simplex virus in a liver transplant recipient. Case: A 27-year-old woman with a history of liver transplant for autoimmune hepatitis-induced cirrhosis underwent a change of medication from tacrolimus to sirolimus, due to chronic kidney disease from a calcineurin inhibitor. Within one week, the patient developed fevers, myalgias, and odynophagia. Prior to transplant, she had negative testing for cytomegalovirus (CMV), IgG Ab, and herpes simplex virus (HSV) type 1 and 2 IgG Ab. Physical exam showed temperature of 102.3°F, multiple shallow ulcers on the tongue and posterior pharynx, and no hepatosplenomegaly or lymphadenopathy. Laboratory tests showed white blood cell count of 4,100 cells/mm3, hemoglobin 11.5 g/dL, hematocrit 35.7%, platelet count 167,000 cells/mm3, creatinine 1.85 mg/dL (baseline 1.5 mg/dL), sirolimus trough 5.7 μg/L and normal liver chemistries. CMV PCR, EBV PCR, and HIV Ab were negative. The ulcers from the oropharynx were sampled; cultures were positive for HSV. An upper endoscopy showed exudates at the gastroesophageal junction with no ulcers. Esophageal biopsies showed numerous HSV-infected squamous cells. HSV-associated erosive esophagitis was confirmed by immunostaining. Serum HSV-1 IgM Ab was positive, confirming a primary herpes infection causing esophagitis. HSV-2 IgM Ab was negative. The patient was started on acyclovir with improvement of her symptoms, and discharged home on valacyclovir. Discussion: The esophagus is the visceral organ most commonly affected by herpes, although it is not uncommon to have concurrent oral lesions. Herpes esophagitis is most commonly found in the immunocompromised patient, especially bone marrow and solid organ transplant patients. The vast majority of cases are caused by HSV-1. The typical findings found endoscopically are well-circumscribed ulcers that have a “volcano-like” appearance. However, exudates and plaques may be the only findings endoscopically. Biopsies and/or brushings should be taken from exudative areas and the edge of ulcers, where the virus that infects the squamous epithelium are most likely to be present. Oral acyclovir is recommended as therapy in the immunocompromised patient. If symptoms are severe, intravenous acyclovir may also be used. Viscous lidocaine provides only modest symptomatic benefit. Opportunistic infections, including HSV, should always be considered in immunocompromised patients who present with fever. This is particularly the case in patients with oral lesions or esophageal complaints.

True enteroliths linked to non-specific multiple ulcers of the small intestine: report of a case.

This report presents a case of true enteroliths linked to non-specific multiple ulcers of the small intestine (CNSU). A 53-year-old male presented with abdominal pain and vomiting, and was admitted to our hospital under a diagnosis of ileus. He had anemia and hypoalbuminemia. Abdominal computed tomography showed that several radio-opaque bodies were present in the dilated small intestine. Double-balloon enteroscopy revealed an eccentric stricture accompanying a linear open ulcer. Well defined oblique and branching ulcers were continuous with the stricture. At laparotomy, we observed 18 stenoses of the small intestine from 190 cm to 110cm proximal to the ileocecal valve. The stenotic and dilated segments were 1.7±0.4 and 5.4±3.0 (mean±SD) cm in width, respectively. He underwent a resection of the affected small intestine. The macroscopic observation revealed various types of multiple shallow ulcers that were linear or had a tall, triangular configuration, and their alignment was circular or oblique. The ulcers had fused, thus showing a geographic configuration. The microscopic findings showed the maximum depth of the ulcers to be the submucosal layer. The enteroliths were mainly composed of calcium oxalate. As a result, the patient was diagnosed as having true enteroliths linked to CNSU. True enteroliths are a rare complication of CNSU.

An Unusual Cause of Diarrhea in an Immunocompromised Patient

Question: A 64-year-old man with a history of chronic hepatitis C and alcoholic cirrhosis underwent orthotopic liver transplantation 4.5 months prior. His course was complicated by moderate acute cellular rejection and he was maintained on tacrolimus 2mg twice daily, sirolimus 5 mg/d, prednisone 25 mg/d, and mycophenolate mofetil 1000 mg twice daily (quadruple immunosuppression). Soon after initiation of quadruple immunosuppression, he was transferred to our hospital for 3 weeks of watery, nonbloody diarrhea. He denied nausea or vomiting. The patient did not have any other relevant medical history. On presentation, physical examination was significant for mild, diffuse abdominal tenderness without rebound or guarding. Laboratory workup was notable for thrombocytopenia (platelets 56,000/mL), metabolic acidosis (bicarbonate 14 mmol/L), acute renal failure (creatinine 4.2 mg/dL), and normal liver function tests. Stool culture, ova and parasites, and Clostridium difficile toxin were negative. A colonoscopy was performed, which showed multiple large, shallow ulcers (Figures A and B). Histology revealed colonic mucosa with ulceration, granulation tissue, and mild acute inflammation. Cytomegalovirus and herpes simplex virus immunostains were negative. While in the hospital, the patient developed new generalized tonic clonic seizures. Magnetic resonance imaging of the brain showed a peripherally enhancing mass in the left frontal lobe measuring 3.2 3.1 3.3 cm concerning for an abscess. What is the diagnosis and what would be the next diagnostic step? Look on page 697 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

P2.029 All That is Genital is Not Venereal

ALL THAT IS GENITAL IS NOT VENEREALUnusual cases with lesions on genitalsGenital disease (GD) has a broad spectrum. Though sexual transmission obviously plays a major role in its pathogenesis, many...

Treatment of Refractory Lower Extremity Ulcer Associated with Sneddon's Syndrome

Treatment of Refractory Lower Extremity Ulcer Associated with Sneddon's Syndrome