No abstract

No abstract

INTRODUCTION: Kaposi sarcoma (KS) is a low grade angioproliferative tumor. AIDS-related KS is the most common and aggressive form of KS. The prevalence of AIDS-related KS is up to 30%. Skin is the most commonly affected organ in 78% of cases, The gastrointestinal (GI) tract is the most commonly affected extracutaneous site, and often asymptomatic. In advanced cases, patients may present with GI bleeding, diarrhea, protein-losing enteropathy, intussusception, or perforation. Although only 20% of KS patients experience GI symptoms, some studies have found that up to 80% of KS patients have GI lesions at autopsy. With the advent availability of HARRT therapy, the incidence of Kaposi sarcoma has decreased dramatically. Our objective is to present an unusual presentation of Kaposi sarcoma and its endoscopic findings leading to the diagnosis of KS, to share how endoscopy can be used as a tool for diagnosing and assessing the GI involvement in KS. CASE DESCRIPTION/METHODS: A 35-year-old African American male with HIV, syphilis, and hepatitis B complains of swelling of his legs and scrotum for 2 months. Physical examination revealed abdominal distension, bilateral lower extremity edema, and one skin nodule on his right foot. Laboratory studies revealed Hgb 8.7 g/dL, MCV 95.3 fL/cell, WBC 7500/cmm, CD4 count < 80 cells/uL, and albumin 1.4 g/dL. CT imaging revealed significant abdominal ascites (Figure 1). The patient underwent paracentesis removing 3.5 L of milky fluid. Fluid culture, gram stain and cytology were negative. Given the ascites and hepatitis history, an esophagogastroduodenoscopy (EGD) was completed in evaluating for possible esophageal varices. EGD revealed a nodular fungating lesion that extends diffusely from the gastric body into the duodenal bulb and sweep (Figures 2 and 3). Biopsy revealed cylindrical cells positive for HHV-8, confirming the diagnosis of gastric Kaposi's sarcoma (KS). Immunohistochemical analysis of the skin nodule biopsy confirmed KS. Computed tomography scan of the chest was consistent with pulmonary metastases. Patient is being treated with HAART and will be started on chemotherapy. DISCUSSION: KS is a rare neoplasm, and an AIDS-defining illness in HIV patients. About 40-51% of HIV patients with cutaneous KS will develop gastrointestinal KS, which is typically asymptomatic until growth is extensive enough to cause abdominal pain. This case illustrates the importance of endoscopic evaluation in HIV patients for early detection of gastrointestinal involvement of KS.

Nutcracker syndrome (NCS) (also known as Left renal vein (LRV) entrapment syndrome), is a rarely reported condition characterized by compression of the LRV leading to a clinical symptoms(1). Here we present a rare case of secondary membranous nephropathy (MN) with NCS. CASE PRESENTATION: A 47 year old male presented with complaints of generalized swelling associated with left flank pain and breathlessness for 2 weeks. Physical exam showed anasarca and varicocele. Laboratory results were significant for hypoalbuminemia (2.2 g/dL) and proteinuria (4.6 g/dL) suggestive of nephrotic syndrome. On chest x-ray, a left sided pleural effusion was noted which was transudative in nature on thoracentesis. Renal doppler ultrasound showed narrowed left renal vein with prominent collateral vessels. CT venography demonstrated a tiny caliber of the LRV secondary to stenosis at the level of the superior mesenteric artery and aorta suggestive of Nutcracker anatomy. Renal biopsy showed secondary MN, with negative PLAR-2 (phospholipase A2 receptor antibodies) staining with negative serum PLAR-2, indicating secondary MN. Malignant, infectious and autoimmune causes of secondary MN were ruled out. He was started on conservative management with lasix, losartan, atorvastatin and prednisone.

INTRODUCTION: Adult gastric volvulus is generally diagnosed by the symptoms of abdominal or chest pain. Acute presentation include symptoms of pain, vomiting, and failure of placement of naso-gastric tube (NGT) also known as Borchardt Triad. Severity of sequelae is dependent on significance of the rotation with rotations of >180° causing possibly outlet obstruction, strangulation, necrosis leading to perforation and severe sepsis leading to death. CASE DESCRIPTION/METHODS: A 92 year old gentleman is admitted for UTI related sepsis and started on antibiotics. On day 8 of his admission, patient complained of abdominal epigastric pain and had two episodes of dark red colored particulate emesis. Hemoglobin was stable and physical exam showed mild distention and slight tenderness on palpation but was otherwise nonsignificant. Multiple attempts at nasogastric tube placement were difficult due to resistance during insertion at below oro-pharyngeal levels. Abdominal CT scan (Figures 2 and 3) was completed showing left diaphragmatic hernia with herniation of the stomach with upside down stomach is noted with partial gastric outlet obstruction with the distended stomach, indicating organo-axial volvulus. This was not obviously noted in the admission chest X-ray (Figure 1). Given requirement for gastrostomy, patient was transferred to hospital of their choice where he subsequently received surgery and was discharged 4 months later. DISCUSSION: The diagnosis of gastric volvulus in this patient was not initially apparent as his abdominal pain complaints were very mild, his labs were normal and stable, and his initial admission was for sepsis. It was primarily the resistance in the placement of the NGT and the coffee-ground emesis that raised suspicion and prompted the CT imaging scan, which revealed the diagnosis. Therefore, it is important to have medical professionals remain cognizant of the possibility of the diagnosis of gastric volvulus, no matter how rare, in an elderly patient with resistance to NGT placement. And although the Borchardt triad is apparent in 75% of acute gastric volvulus cases, it is important to remember that up to 25% of patients do not present classically, and therefore gastric volvulus should not be excluded as a possible diagnosis.