A case report and review of the literature

Abstract

Abstract. A case of an incidental endoscopic finding of pneumatosis cystoides intestinalis in the large bowel is presented. Diagnosis was verified by fine needle aspiration cytology. Basic facts about this uncommon entityare reviewed with an emphasis on endoscopic differential diagnosis. CASE REPORT / KAZUISTIKAPneumatosis cystoides intestinalis is a rare gastrointestinal condition, in the majority of cases an incidental finding which represents a differential diagnostic challenge for endoscopist, radiologist, pathologist and physician. Case reportA 51-year-old man underwent colonoscopy elsewhere for diarrhoea and slight haematochezia and he was then referred to our endoscopy unit for supervision because of finding several polyps in the hepatic flexure region. During colonoscopy we found several sessile polyps clustered in streaks, covered with normal mucosa, quite firm on probe palpation (Fig 1 and 2). Biopsy attempts just unroofed normal mucosa away, but polyps disappeared during the puncture and suction with a cytology needle. This typical endoscopic picture led us to suspicion of pneumatosis cystoides intestinalis. Material aspirated from cysts was smeared on cytology glass. Microscopically, two cell populations were visible -epithelial cells of colonic mucosa, arranged in a honeycomb pattern and numerous multinucleated giant cells of foreign body type (Fig 3) and this confirmed our suspicion.The patient was symptom-free at that time, no pathology was found on abdominal plain X-ray. DiscussionPneumatosis cystoides intestinalis is a rare condition characterized by the presence of gas-filled pseudocysts in the wall of gastrointestinal tract. This condition can be combined with the presence of gas in omentum, mesentery, peritoneal cavity, retroperitoneum and portal venous system (2,6,25,28). The first cases of pneumatosis cystoides intestinalis were described by DuVernoi in the 18th century in postmortem studies (cited from ref. 27).Aetiology and pathogenesis of pneumatosis cystoides intestinalis are not clearly known -intraluminal pressure, bacterial flora, intraluminal gas and muco-

Primary diffuse leptomeningeal gliomatosis mimicking a chronic inflammatory meningitis

“…CSF studies generally reveal a pleocytosis, markedly elevated protein, and normal or low glucose. Brain and spine imaging show diffuse leptomeningeal enhancement in the absence of an intraaxial mass [3]. The leptomeningeal enhancement may predominate along the posterior cranial fossa and lumbosacral spinal canal.…”

“…In addition, on fluidattenuated inversion recovery (FLAIR) sequences, there can be a characteristic diffuse high intensity area in the subarachnoid space and the fourth ventricle. This finding on FLAIR imaging may be the result of markedly elevated protein content and occupation of the subarachnoid space by neoplastic cells [3]. As a result of non-specific CSF and radiographic findings, meningeal biopsy is generally considered the most definitive diagnostic approach.…”

“…Positive identification of malignant cells via repeated examination of CSF is possible in approximately 80% of cases in leptomeningeal carcinomatosis [7,8] and 66% in secondary meningeal gliomatosis. In contrast, our review of PDLG shows that patients usually have negative CSF cytologic examinations, despite numerous lumbar punctures [3,5,[9][10][11][12][13]. In fact, only 6 of the 37 PDLG cases with CSF cytology found atypical cells in the CSF [12,[14][15][16].…”

“…There have been less than 50 cases reported in the literature to date and the diffuse form of primary leptomeningeal gliomatosis may present with considerable diagnostic and therapeutic challenges [3]. Since multiple cerebrospinal fluid (CSF) examinations may be nondiagnostic, meningeal and cortical biopsy may be the best means of establishing a definitive diagnosis [4].…”

Diffuse Leptomeningeal Glioneural Tumour Simulating Tuberculous Meningitis in a 13-Year-Old Girl

“…On this basis the antituberculosis therapy was stopped. A biopsy of leptomeninges was performed, characterized by a pearly opacified surface and and spine imaging show diffuse leptomeningeal enhancement in the absence of an intracranial mass [2]. However, a discrete mass in the spinal cord may be identified.…”