RESUMO
The clinical symptoms of an immune checkpoint inhibitor (ICI)-induced colitis are similar to those of ulcerative colitis. ICI-induced colitis, like ulcerative colitis, may be complicated by other colitis, such as Clostridioides difficile infection (CDI). A 72-year-old man was admitted because of watery and bloody stools 10 times a day after three courses of nivolumab (antibodies against programmed death 1) and ipilimumab (cytotoxic T-lymphocyte-associated antigen-4) for stage IV renal cell carcinoma. Colonoscopy revealed erythema and multiple erosions in the colon. Histopathological examination of colonic mucosa revealed diffuse inflammatory cell infiltration and apoptosis. The initial cytomegalovirus antigen test and C. difficile detection assay results were negative. Based on these findings, we diagnosed the patient with ICI-induced colitis and discontinued ICI therapy. The symptoms did not improve despite the administration of Prednisolone and infliximab. A repeat colonoscopy revealed a new appearance of pseudomembranes from the sigmoid colon to the rectum one month after the start of these treatments. At this point, the patient tested positive for C. difficile. With treatment with vancomycin for CDI, the abdominal symptoms gradually decreased. Nivolumab alone was cautiously restarted. However, no colitis recurrence and further tumor reduction were observed. Here, we report our experience of a case of refractory ICI-induced colitis complicated by CDI. ICI-induced colitis may be complicated by CDI and should be carefully treated with repeated CDI testing if refractory to treatment. We believe that our observation will provide helpful information for determining an appropriate treatment strategy for ICI-induced colitis.
RESUMO
Acute duodenal perforation during endoscopic ultrasound (EUS) is a serious complication. The conventional endoscopic treatment for duodenal perforations such as endoscopic clipping is unsatisfactory; recently, the effectiveness of over-the-scope clipping (OTSC) has been reported. A 91-year-old woman was referred to our hospital with the chief complaint of jaundice. Contrast-enhanced computed tomography showed a 2-cm mass in the pancreatic head; we planned EUS-guided fine-needle aspiration. During exploration for a puncture route from the duodenal bulb using a linear echoendoscope under carbon dioxide insufflation, the duodenal lumen was suddenly filled with blood. A perforation <15 mm was identified in the superior duodenal horn. We attempted an endoscopic closure with multiple endoclips but could not completely close the perforation site. Strips of bioabsorbable polyglycolic acid (PGA) sheets were placed over the gaps between the endoclips with biopsy forceps and fixed in place with fibrin glue, completely covering the perforation site. Two days after the procedure, the perforation site had closed. Nine days later, endoscopic biliary stenting was performed. The patient was diagnosed with pancreatic cancer through bile cytology, and the optimal supportive care for her age was selected. Endoscopic tissue shielding with PGA sheets and fibrin glue is increasingly being reported for use during gastrointestinal endoscopic procedures. In this case, surgery was avoided due to successful endoscopic treatment using endoclips and PGA sheets with fibrin glue without OTSC. This method may be useful for repairing acute duodenal perforations during EUS and should therefore be known to pancreatobiliary endoscopists.
RESUMO
Systemic immune deficiency is a major cause of cytomegalovirus (CMV) esophagitis. We report a case of CMV esophagitis during topical steroid therapy of eosinophilic esophagitis (EoE) in a non-immunodeficient patient. An 85-year-old man with dysphagia was on a 6-year regimen of oral budesonide (1200 mcg daily) for EoE. He underwent right upper lobectomy and postoperative radiotherapy 25 years ago for lung squamous cell carcinoma. Esophageal cicatricial stenosis due to EoE or previous radiation therapy persisted. Esophagogastroduodenoscopy revealed ulcerating mucosa with a thick white coat originating from the fixed stenotic lesion to the oral side. Histopathological examinations revealed CMV esophagitis. All signs of CMV esophagitis rapidly disappeared after reducing the budesonide dose and initiating anti-viral treatment with ganciclovir and valganciclovir for 12 and 2 days, respectively. The patient continued topical budesonide 400 mcg daily after anti-viral therapy. The clinical course was uneventful and without CMV esophagitis recurrence. This suggests that topical steroid therapy, particularly the local stasis of steroids at stenotic lesions, may induce CMV esophagitis. This is the first report of CMV esophagitis complicating the local steroid therapy of EoE with a stenotic lesion. When EoE patients' clinical symptoms worsen with topical steroid therapy, CMV esophagitis should be considered.
Assuntos
Infecções por Citomegalovirus , Esofagite Eosinofílica , Idoso de 80 Anos ou mais , Citomegalovirus , Infecções por Citomegalovirus/tratamento farmacológico , Humanos , Masculino , Recidiva Local de Neoplasia , EsteroidesRESUMO
While antiretroviral therapy has improved mortality in patients with human immunodeficiency virus (HIV) infections, deaths caused by non-acquired immunodeficiency syndrome-defining malignancies are increasing. A woman in her 70s with HIV infection who was receiving antiretroviral therapy presented with dysphagia. She was diagnosed with esophageal cancer (cT3N2M0, stage III). She received neoadjuvant chemotherapy (cisplatin and 5-fluorouracil) and radiotherapy. During treatment, we continued administering antiretroviral therapy and prophylaxis for opportunistic infections, with due attention to side effects and drug-drug interactions. No severe adverse events occurred. The primary lesion and metastatic lymph nodes decreased in size after treatment; however, 1 month later, her cancer spread to other organs; thus, surgery was canceled. Her general condition rapidly worsened. She eventually died of cancer cachexia and aspiration pneumonia. No previous reports have mentioned the treatment plan and management of esophageal cancer in HIV-positive patients. This report presents a case of esophageal cancer with HIV infection that progressed rapidly after neoadjuvant chemoradiotherapy.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimiorradioterapia , Transtornos de Deglutição/fisiopatologia , Neoplasias Esofágicas/terapia , Carcinoma de Células Escamosas do Esôfago/terapia , Infecções por HIV/tratamento farmacológico , Terapia Neoadjuvante , Idoso , Alcinos , Benzoxazinas/uso terapêutico , Cisplatino/administração & dosagem , Ciclopropanos , Transtornos de Deglutição/etiologia , Progressão da Doença , Interações Medicamentosas , Emtricitabina/uso terapêutico , Neoplasias Esofágicas/complicações , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/patologia , Carcinoma de Células Escamosas do Esôfago/complicações , Carcinoma de Células Escamosas do Esôfago/diagnóstico , Carcinoma de Células Escamosas do Esôfago/patologia , Evolução Fatal , Feminino , Fluoruracila/administração & dosagem , Gastrostomia , Infecções por HIV/sangue , Infecções por HIV/complicações , Humanos , Estadiamento de Neoplasias , RNA Viral/sangue , Insuficiência Renal/induzido quimicamente , Tenofovir/uso terapêutico , Carga ViralRESUMO
BACKGROUND/AIMS: Recently, endoscopic detachable snare ligation (EDSL) has become increasingly common as treatment for colonic diverticular hemorrhage. This study aimed to evaluate the efficacy and safety of EDSL in comparison with endoscopic clipping (EC) as treatment for colonic diverticular hemorrhage. METHODS: From April 2013 to September 2017, 131 patients were treated with EDSL or EC at the Tokyo Metropolitan Bokutoh Hospital. We retrospectively evaluated patient characteristics and clinical outcomes, including early rebleeding rates (rebleeding within 30 days after initial hemostasis) and complications for each procedure. RESULTS: Of 131 patients, 44 and 87 were treated with EDSL and EC respectively. We initially achieved endoscopic hemostasis in all patients. The early rebleeding rate was significantly lower for EDSL (6.8%, 3 patients) than for EC (23.0%, 20 patients). There were no differences in the total procedure time (43 vs. 45 min, p = 0.84) or time to hemostasis after identification of bleeding site (12 vs. 10 min, p = 0.23). There were no severe complications following EDSL. CONCLUSION: The results of this study suggest that EDSL is superior to EC as treatment for colonic diverticular hemorrhage. EDSL may provide improvements in the clinical course of patients with colonic diverticular hemorrhage.