Candesartan-Induced Enteropathy That Mimics Celiac Disease in a 90-Year-Old Patient.

Sprue-like enteropathy (SLE) is a clinical syndrome similar to celiac disease and has been associated with the use of various angiotensin receptor blockers (ARBs), a class of medications frequently used in the management of hypertension. Currently, there has only been one documented case report which has observed this occurrence with the use of the ARB candesartan. A 90-year-old female patient presented with chronic diarrhea and weight loss of unclear etiology. Diagnostic esophagogastroduodenoscopy and ileocolonoscopy were macroscopically unremarkable, but histological samples revealed complete villous atrophy, chronic mucosal inflammation, and intraepithelial T-lymphocytic infiltration. However, serological studies could not confirm celiac disease as a cause for the patient's symptoms of malabsorption. After exclusion of other intestinal inflammation etiologies with noted ongoing candesartan use, the diagnosis of SLE was made, and candesartan therapy was discontinued. Additionally, we decided to initiate a lactose-free diet. Clinical remission was achieved without any recurrences. Candesartan is a commonly prescribed therapeutic agent in the treatment of hypertension. Our case underlines the importance of considering it as a potential cause for unexplained symptoms of malabsorption.

Immune-mediated Gastritis in a Patient with metastatic Lung Cancer due to Therapy with the immune Checkpoint Inhibitor Pembrolizumab - Differences and Similarities in Comparison to "endogenous" autoimmune Type A Gastritis and a review of literature.

Immune checkpoint inhibitors are increasingly used in advanced malignant diseases and are well-known for their good results. With the blockade of immune checkpoints, the probability of immune-related adverse events is also increased.We present a 54-year-old female patient with advanced NSCLC. She was treated with pembrolizumab and developed a stable disease under therapy. After six cycles, she presented with massive epigastric pain to our emergency department. Gastroscopy showed severe erosive-fibrinous pangastritis without the involvement of the esophagus, duodenum, or other immune-related adverse effects. Histology showed the complete destruction of the gastric mucosa. We concluded an immune-mediated gastritis by pembrolizumab, after the exclusion of other differential diagnoses.Despite treatment with prednisolone and marked improvement of her symptoms, the mucosa was never fully reconstituted into a healthy mucosa.Furthermore, we collected published reports of similar cases and conducted a comparison with features of a typical, endogenous type A gastritis to highlight similarities and differences.

The diagnostic challenge of abdominal tuberculosis in nonendemic countries: A case series from a tertiary hospital in Germany.

Abdominal tuberculosis is a rare clinical condition in nonendemic countries and should be included as differential diagnosis by unspecific abdominal complaints, especially in patients with immigration background from high-prevalence regions.

CMV Colitis in Immunocompetent Patients: 2 Cases of a Diagnostic Challenge.

CMV infections are generally thought to be opportunistic by immunosuppression. Many literature cases though indicate that CMV infections can be also observed in immunocompetent patients. We present an unusual case of an extensive concentric benign stenosis due to CMV colitis and a case of coexistence with Crohn's Disease, both observed in nonimmunosuppressed individuals. The right diagnosis was set after implementation of multiple unsuccessful treatment strategies. Our purpose is therefore to familiarize clinicians involved with the diagnosis and treatment of gastroenterological diseases with this entity.

Analysis of chromosomal imbalances by comparative genomic hybridisation of pigmented villonodular synovitis.

Using comparative genomic hybridisation, DNA copy number changes were investigated in 15 cases of pigmented villonodular synovitis of the knee joint. Additionally DNA content was analysed by flow cytometry. Screening revealed numerical chromosomal imbalances in five of the examined cases. A total number of 18 gains were detected. The most frequent gains involved subregions of chromosomal arms 22q and 16p and 16q. No losses were found. One of the cases showed an aneuploid DNA-pattern, which actually proved to be the case with the most numerical chromosomal changes.

Expression of cell cycle-related gene products in different forms of primary versus recurrent PVNS.

Expression patterns of cell cycle regulating gene products and Ki-67 in proliferating synovial cells of primary and recurrent pigmented villonodular synovitis (PVNS) in localized and diffuse lesions were examined by immunohistochemistry. Alterations of cell cycle-related proteins were seen in 98.7% of analyzed lesions. Both RB- and p53 pathways play a role in cell cycle dysregulation in PVNS. The RB pathway was more frequently altered in primary disease, while alterations of the p53 pathway seemed to be more important in recurrent lesions, regardless of the histomorphological type of disease. Ki-67 proliferation rate was elevated in recurrent tumors.

Detection of hematogenic and lymphogenic tumor cell dissemination in patients with medullary thyroid carcinoma by cytokeratin 20 and preprogastrin-releasing peptide RT-PCR.

Despite an extensive surgical approach only 50% of the patients with medullary thyroid carcinoma (MTC) are biochemically cured. The failure to cure a larger number of patients is a result of the early dissemination of MTC. The present study evaluates two RT-PCR based assays for the detection of disseminated tumor cells in blood, bone marrow and lymph node samples of patients with MTC. Frozen tissue and blood samples of 19 patients with MTC and 61 cervical lymph nodes of these patients were obtained intraoperatively during thyroidectomy and lymphadenectomy. Preoperative bone marrow samples were obtained from 8 patients with MTC. An expression of CK20 and preproGRP was found in all MTC tissue samples. Using CK20-PCR, disseminated MTC cells were detected in 67% of the cervical lymph nodes of patients with MTC, compared to 72% involved lymph nodes, detected by preproGRP-PCR. In 16 of 61 nodes (26%) each PCR-system detected disseminated tumor cells in histologically tumor-free lymph nodes. Disseminated tumor cells were detected with CK20-PCR and preproGRP in 5 of 18 (28%) preoperative blood samples, each. The detection of a hematogenic tumor cell dissemination by preproGRP correlated significantly with the tumor stages (p = 0.019). Circulating MTC cells were found in 3 of 8 bone marrow samples with CK20-PCR, compared to 1 of 8 samples with preproGRP-PCR. Both PCR assays are highly sensitive to detect disseminated MTC cells in blood, bone marrow and lymph node samples. Our results of disseminated MTC cells in 26% of histologically tumor-free cervical lymph nodes and in 28% of the blood samples of patients with MTC might therefore explain the low biochemical cure rates.

Cytokine/chemokine messenger-RNA expression profiles in ulcerative colitis and Crohn's disease.

To define mediator profiles in inflamed and noninflamed areas in inflammatory bowel disease (IBD) we analyzed the expression of 35 messenger-RNAs (mRNAs) encoding cytokines, chemokines, and some related molecules in transmural gut tissues (n=138) from patients with ulcerative colitis (UC), Crohn's disease (CD), and inflammatory and normal controls by real-time quantitative reverse transcription polymerase chain reaction. Using sample collectives with a comparable degree of inflammation, most parameters investigated showed similarly increased mRNA expression levels in both active UC and CD. This included proinflammatory cytokines, but also interferon (IFN) gamma and several IFN-gamma inducible chemokines. Only macrophage inflammatory protein (MIP)-2alpha mRNA was expressed at higher levels in inflamed UC vs. CD. IH revealed that MIP-2alpha protein was produced mainly by intestinal epithelial cells. Importantly, in histologically noninflamed/inactive IBD samples mRNAs for several mediators were significantly enhanced, accompanied by elevated levels of migration-inhibition factor related protein (MRP) 14 transcripts. CD14 positive macrophages were found especially in noninflamed/inactive UC, many of which coexpressed the RFD-7 antigen. Our results indicate a substantial overlap in cytokine/chemokine mRNA expression in UC and CD. Elevated mediator expression is evident in noninflamed/inactive areas in both diseases. Local recruitment of MRP-14 positive leukocytes might contribute to this phenomenon. In inactive UC a phenotypically altered population of macrophages expressing CD14 might play an additional role.

Detection of disseminated medullary thyroid carcinoma cells in cervical lymph nodes by cytokeratin 20 reverse transcription-polymerase chain reaction.

Local recurrence in differentiated and medullary thyroid carcinoma develops frequently from metastatic infiltration of cervical lymph nodes. Despite an aggressive surgical approach, postoperative calcitonin levels as biochemical evidence for residual cancer cells remain often elevated in patients with medullary thyroid carcinoma. In the present study, we compared the detection rates of disseminated medullary thyroid carcinoma cells in cervical lymph nodes by histopathology with reverse transcription-polymerase chain reaction (RT-PCR) amplification of cytokeratin 20 (CK20) transcripts as a more sensitive but still specific molecular parameter for residual thyroid cancer cells. Forty-two cervical lymph nodes obtained from 7 patients with CK20positive medullary thyroid carcinomas were cut into two halves, one used for conventional histology, the other subjected to RNA extraction and subsequent amplification of cytokeratin 20 transcripts. Matching results for CK20 RT-PCR and histopathology were found in 74% (31/42)of the examined lymph nodes (52% positive results, 48% negative results). Positive CK20 RT-PCR pointed to residual thyroid carcinoma cells in another 19% (8/42), in which no thyroid carcinoma cells were identified by histopathology. Histology and immunohistochemistry,however, identified tumor cells in 7% (3/42) of the analyzed lymph nodes, from which no CK20 transcript could be amplified (false-negative results). These data suggest that CK20 RT-PCR might be more sensitive to detect nodal involvement of CK20 positive medullary thyroid carcinomas than conventional histopathology. In combination with histology, it might help to identify patients with residual disease after surgery.