Case Study in 2010

Epstein–Barr virus (EBV) infection with gastrointestinal tract involvement is extremely rare in immunocompetent adults. This Case Study describes an immunocompetent 30-year-old man who presented with several months of bloody diarrhea and cramping abdominal pain, suggestive of IBD. However, viral serologic tests confirmed acute EBV infection, and EBV-associated lymphoproliferative disorder of B-cell lineage with diffuse colonic involvement was diagnosed.

This article discusses the case of a 63-year-old woman who presented with dysphagia 27 years after she received radiation therapy for Hodgkin disease. She was diagnosed with a large tracheoesophageal fistula and poorly differentiated squamous cell carcinoma of the esophagus. The authors describe, for the first time, successful surgical management of this complex clinical condition.

A 37-year-old female was given esomeprazole to treat reflux-like dyspeptic symptoms ∼3 years after undergoing surgery for a neuroendocrine pancreatic neoplasm. During esomeprazole treatment, her serum chromogranin A level rose to around three times the upper limit of normal, but her gastrin levels remained in the normal range. Relapse of the neuroendocrine tumor was suspected; however, investigations led to a diagnosis of esomeprazole-induced hyperchromograninemia in the absence of elevated levels of fasting serum gastrin.

A 38-year-old female was evaluated for a 3 year history of postprandial abdominal pain, refractory nausea, vomiting and hematemesis. Her medical history was significant for juvenile polyposis syndrome and Crohn's disease resulting in a total colectomy. Juvenile polyposis syndrome with outlet obstruction of the stomach and excessive hypergastrinemia was diagnosed and treatment started with acid suppressive therapy, prokinetic therapy and total parenteral nutrition. Repetitive endoscopic polypectomy (also known as debulking) was performed twice followed by gastrectomy with duodeoesophageal anastomosis.

This article considers the case of a 72-year-old woman who presented with a 2-month history of right upper quadrant abdominal pain and a 15-day history of jaundice. The patient was diagnosed with bile duct duplication and coexistent cholangiocarcinoma. This Case Study explores the diagnosis and management of this patient and is believed to be the first reported case in the literature of this unique variant of bile duct duplication.

A 72-year-old man was evaluated for dysgeusia, diarrhea and ano-rexia. 3 months earlier he began to experience taste changes, a de-cline in appetite and 3–7 loose, non-bloody stools per day, followed by nausea, lower abdominal cramping and weight loss of 22.68 kg. Cronkhite–Canada syndrome was diagnosed and treatment started with prednisone, a histamine-2-receptor blocker and oral micronutrient supplementation. All visible polyps were removed and subtotal colectomy with end-to-side ileorectostomy per-formed.

A 33-year-old woman with a history of paroxysmal nocturnal hemoglobinuria (PNH) presented with abdominal pain, nausea and vomiting, accompanied by duodenal wall thickening seen on an abdominal CT scan and an ischemic-looking duodenal mucosa as visualized by endoscopy. She was diagnosed as having small bowel ischemia complicating PNH. Treatment with warfarin was started, but ischemic episodes recurred. Treatment with eculizumab was, therefore, proposed. This case highlights this rare gastrointestinal complication of PNH.

A 50-year-old man from Las Vegas with a history of complicated Crohn's disease and who had received adalimumab therapy presented with left lower quadrant abdominal pain, periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain and weight loss. He was diagnosed with having disseminated coccidioidomycosis. Despite antifungal treatment, surgical debridement and irrigation, and discontinuation of immunosuppressive therapy, the patient eventually died. This case highlights the risk of developing endemic mycoses while receiving biologic therapy.

This article considers the case of a 17-year-old adolescent with a history of Crohn's disease who was receiving infliximab and presented with a new-onset rash. The rash did not resolve with corticosteroid treatment and worsened after further treatment with infliximab and also after subsequent administration of adalimumab. He was diagnosed as having an anti-TNF agent induced psoriasiform rash. The rash resolved after discontinuation of anti-TNF agents and his rash has not recurred during 3 years of follow-up.