11/24. association of thrombotic thrombocytopenic purpura and human immunodeficiency virus infection. A 35 year-old HIV-positive male intravenous drug abuser developed thrombotic thrombocytopenic purpura (TTP) during the course of recto-sigmoiditis secondary to shigella flexneri. Complete remission was achieved by aggressive treatment of a combination of plasma exchange, fresh frozen plasma infusion, continuous prostacyclin perfusion, p.o. administered aspirin-dipyridamol and intravenous injections of vincristine. During acute microangiopathy, an acquired type II von Willebrand disease was diagnosed. TTP is a newly-recognized hematologic manifestation of hiv-1 infection; endothelial damage by endotoxin during course of infection or by high serum levels of circulating immune complexes may be a causative mechanism of microangiopathy causing hemolysis and platelet consumption. ( info) |
12/24. Colitis cystica profunda: an unusual surgical problem. Colitis cystica profunda is a rare, benign, non-neoplastic condition which usually presents as a mass in the rectum associated with bloody, mucoid diarrhea. This clinical presentation associated with the microscopic finding of mucus cysts in the submucosa has led to the mistaken diagnosis of adenocarcinoma of the rectum and unnecessarily radical operative procedures. attention to the completely normal cellular architecture provides the key to the correct diagnosis. Local excision is curative, and there is no propensity to develop malignancy in these patients. Experience with one case is reported, and the medical literature on the subject is reviewed. ( info) |
13/24. Colonic inflammation and nonsteroidal anti-inflammatory drug administration. An assessment of the frequency of the problem. Over an 18-month period at a single clinic, 43 new cases of colonic inflammation have been diagnosed (19 proctitis only). Crohn's colitis has been excluded from this analysis. In all these subjects a careful drug history has been taken in a prospective manner and in 4 of these 43 patients colonic inflammation appeared to be directly related to non-steroidal anti-inflammatory drug (NSAID) administration (mefenamic acid, 2; piroxicam, 2). In all 4 patients there was a time interval (mean 3 months) between initiation of treatment with NSAID and presentation with diarrhoea and weight loss. Pathological findings were minor and biochemical changes insignificant, in contrast to the protracted troublesome symptoms. Resolution of symptoms was very rapid on discontinuation of NSAID medication but 2 patients experienced immediate return of symptoms following inadvertent rechallenge. Approximately 10% of newly diagnosed colitis may be related to NSAID administration. Subjects taking NSAID medications appear to be five times more likely to develop colonic inflammation than the general population. ( info) |
14/24. isotretinoin-associated proctosigmoiditis. A 17-yr-old boy developed acute proctosigmoiditis after the institution of isotretinoin for the treatment of cystic acne vulgaris. Painless diarrhea, accompanied by mucus and eventually blood, began within days of commencing treatment and persisted while the drug was administered. At sigmoidoscopy patchy mucosal inflammation associated with numerous discrete aphthous ulcers was seen, apparently restricted to the rectosigmoid. Histologic examination of the affected mucosa revealed an acute focal superficial inflammatory infiltrate. Withdrawal of the drug resulted in prompt resolution of symptoms and a reduction in the severity of the inflammation. Rechallenge with isotretinoin induced a second, almost identical, attack of proctosigmoiditis. Withdrawal was again followed by disappearance of symptoms, and a subsequent sigmoidoscopy and mucosal biopsy were normal. The patient has remained clinically well for 16 mo after his initial presentation. Although the pathogenesis of the colonic mucosal inflammation remains unknown, the relationship of the bouts of proctosigmoiditis to the administration of isotretinoin strongly suggests that the drug was directly responsible. ( info) |
| A 37-year-old homosexual man was evaluated for a one-week history of hematochezia. Results of a physical examination were remarkable only for grossly bloody stool. sigmoidoscopy to 30 cm showed a friable mucosa compatible with an acute colitis, and a rectal biopsy specimen demonstrated an increased plasma cell infiltrate. Stool cultures subsequently yielded aeromonas hydrophila; serum human T-cell lymphotropic virus type III antibody titer was positive. The patient responded to a course of treatment with sulfamethoxazole and trimethoprim with resolution of his symptoms and restoration of the bowel to a normal sigmoidoscopic appearance. aeromonas hydrophila infection should be considered in the differential diagnosis of acute proctocolitis, particularly in patients with underlying immunodeficiency states. ( info) |
16/24. Colitis caused by non-steroidal anti-inflammatory drugs. Four cases of acute proctocolitis associated with non-steroidal anti-inflammatory drug therapy are presented. The drugs implicated were flufenamic acid, mefenamic acid, naproxen and ibuprofen. After resolution of symptoms and signs of proctocolitis three of the four patients were subsequently rechallenged with the implicated drug: in each there was a rapid relapse. ( info) |
17/24. proctocolitis caused by concurrent amoebiasis and gonococcal infection. The "gay bowel syndrome". The simultaneous occurrence of amoebic proctocolitis and gonococcal proctitis in a male homosexual in Sydney is reported. attention is drawn to the occurrence of multiple or sequential venerally transmitted intestinal infections among male homosexuals. ( info) |
18/24. Sudden reversal of renal failure after take-down of a jejunoileal bypass. Report of a case involving hemorrhagic proctocolitis, and renal and hepatic failure late after jejunoileal bypass for obesity. Hepatic and renal failure developed in association with severe enteritis and hemorrhagic proctocolitis in a patient who had had a jejunoileal bypass 8 yr previously for morbid obesity. Parenteral antibiotic treatment abolished the systemic manifestations of the enteritis, but did not change the course of the hepatic and renal failure, and prolonged hemodialysis was necessary. liver function improved in response to hyperalimentation. Take-down of the jejunoileal bypass resulted in immediate improvement of renal function, and hemodialysis could be discontinued. Although there is no direct evidence supporting this theory, the course of this patient suggested that the renal failure was functional in origin, and was caused by a toxin generated as a result of the intestinal bypass. We suspect that the toxin originated from bacteria within the blind bowel loop. Its delivery to the renal circulation was probably facilitated by increased absorption from the ulcerated large intestine and by impaired clearance by the diseased liver. When the bacterial flora were returned toward normal by take-down of the bypassed intestine, the quantity of circulating toxins probably decreased, which allowed renal function to improve. ( info) |
| A case of reactive arthritis in a patient with a previously documented history of Reiter's syndrome is described. The precipitating agent appears to have been clostridium difficile. High levels of toxin were demonstrable in the faeces and neutralising antitoxin was detected in the patient's serum but not synovial fluid. Resolution of the polyarthropathy was slow despite successful eradication of the C. difficile with a course of vancomycin. ( info) |
| A patient with common variable immunodeficiency disease is described with severe colitis confined to the rectosigmoid region. inflammation was extensive in the regions involved and exhibited a character that we believe is most unusual. inflammation was transmural in the regions involved. macrophages were the major inflammatory cells, and no granulomas or giant cells were seen. Although the disorder seemed distinct from either ulcerative colitis or Crohn's disease, the colitis responded favorably to oral azulfidine, prednisone, and to steroid enemas. ( info) |