Azathioprine in refractory sprue.

We report a patient with life-threatening refractory sprue who was dependent on high doses of corticosteroids to prevent severe diarrhea, malabsorption, and villous atrophy. Azathioprine allowed tapering of corticosteroids to lower doses, while maintaining remission in histology and in objective measures of malabsorption. Immunosuppressive therapy, however, is not without risks, particularly in patients with associated hypoglobulinemia.

Minocycline-induced hepatitis with autoimmune features and neutropenia.

Minocycline can cause various types of hepatotoxicity. We report an 18-year-old male who developed a delayed onset of minocycline-induced cholestatic hepatitis with autoimmune features and neutropenia. He responded to withdrawal of the drug and a short course of corticosteroids. If minocycline is to be administered, then periodic monitoring for hepatoxicity is recommended.

Inorganic phosphorus reduces hypercalciuria during total parenteral nutrition by enhancing renal tubular calcium absorption.

BACKGROUND: Increasing the inorganic phosphorus content of total parenteral nutrition (TPN) formulas has been shown to decrease TPN-induced hypercalciuria in experimental animals and humans. The mechanism of this effect, however, has been uncertain. METHODS: By using a randomized cross-over design, seven patients on cyclic TPN were given otherwise identical formulas providing either 15 or 45 mmol/d of inorganic phosphorus. Urinary calcium excretion, serum ultrafilterable calcium, filtered calcium load, fractional calcium excretion, urinary cyclic adenosine 5'-monophosphate (cAMP), and serum levels of ionized calcium, parathyroid hormone (PTH), and vitamin D metabolites were determined at the end of each study period. RESULTS: Urinary calcium excretion was significantly lower when the patients received the higher inorganic phosphorus formula. Increasing the inorganic phosphorus in the TPN formula did not change ultrafilterable calcium or filtered calcium load, but significantly reduced fractional calcium excretion. No differences in serum levels of ionized calcium, PTH, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, or urinary cAMP were observed between treatments. CONCLUSIONS: These results demonstrate that increasing the inorganic phosphorus content of the TPN formula decreases urinary calcium excretion by increasing renal tubular calcium resorption. This effect is not due to alterations in the PTH-1,25-dihydroxyvitamin D axis, but likely reflects a direct action of inorganic phosphorus on the renal tubules.

Ileocecal intussusception of small-bowel lymphoma: diagnosis by colonoscopy.

Intussusception is rare in adults. There is little information on the role of colonoscopy in colonic intussusception. We report, to our knowledge, the first adult case of small-bowel lymphoma causing ileocecal intussusception in which the diagnosis was made by colonoscopy. Colonoscopy has a useful role in the diagnosis and management of ileocecal intussusception.

Esophageal carcinoma presenting with nephrotic syndrome: association with anti-neutrophil cytoplasmic antibody.

Malignancy is a cause of membranous glomerulonephritis. We report a patient with an otherwise asymptomatic squamous cell carcinoma of the esophagus whose presenting manifestation was membranous glomerulonephritis and nephrotic syndrome. Perinuclear anti-neutrophil cytoplasmic antibody was positive. This is the first reported case of perinuclear anti-neutrophil cytoplasmic antibody associated with paraneoplastic glomerulonephritis and nephrotic syndrome due to esophageal squamous cell carcinoma.

Gastric inlet patch containing submucosally infiltrating adenocarcinoma.

We describe a patient with an unusual segment of ectopic gastric mucosa in the proximal esophagus. The gastric heterotopia was circumferential and unusually long at 7 cm. It contained benign rugal-type folds, a stricture at the mid-portion of the gastric inlet patch was lined by normal antral-type gastric mucosa but harbored submucosally infiltrating adenocarcinoma. There was no evidence of Helicobacter pylori infection by biopsy or serologic screening. Malignancy, including submucosally infiltrating adenocarcinoma, should be considered in patients with strictures involving ectopic gastric mucosa in the proximal esophagus.

Plasma exchange for dramatic gestational hyperlipidemic pancreatitis.

We describe the response to plasma exchange in a woman with extreme gestational hyperlipidemia and severe pancreatitis. Her serum triglyceride reached an astounding level of 21,300 mg/dl-among the highest concentrations ever recorded. Two consecutive plasma exchanges led to a remarkable reduction in triglyceride levels of 73% and 82%, respectively. Plasma viscosity decreased by 50% after the first plasma exchange. This was associated with an equally dramatic and unexpectedly rapid resolution of severe pancreatitis. Plasma exchange can rapidly and safely resolve extreme hyperlipidemia and be associated with prompt resolution of pancreatitis in women with severe gestational hyperlipidemic pancreatitis.

Nortriptyline-induced fulminant hepatic failure.

We describe, to our knowledge, the first reported case of nortriptyline-induced fulminant hepatic failure. This tricyclic antidepressant drug was taken by a postmenopausal woman for 64 days before her presentation. The absence of fever, rash, or marked eosinophilia, the predominant zone 3 necrosis with bridging, and the latent period favor a metabolic idiosyncratic reaction. The fatal outcome underscores the importance of recognizing the association and discontinuing the offending agent.