Severe Hypocalcemia as an Atypical Manifestation of Seronegative Celiac Disease in a Patient with Systemic Lupus Erythematosus: Case Report

Aim: To describe the clinical picture and diagnosis of an episode of severe hypocalcemia in a patient with systemic lupus erythematosus (SLE) in remission, with chronic diarrhea that led to the diagnosis of celiac disease (CD). Case presentation: 22-year-old patient, diagnosed with SLE at age 10, in remission. He consulted for a two-month history of paresthesias, muscle spasms, myalgias, and episodes of tetany in the previous week, associated with malabsorptive postprandial diarrhea. His laboratory tests showed severe hypocalcemia, vitamin D deficiency, severe hypomagnesemia, and mild hypokalemia. In the study for CD, serology reported normal anti-tissue transglutaminase IgA, antigliadin IgA, and IgG and low total IgA levels. Enteroscopy revealed erosive bulbo-duodenitis, with villous atrophy and increased intraepithelial lymphocytes in the pathology, which, together with the immunohistochemical study, allowed the diagnosis of CD, Marsh 3a type. Management was initiated with a gluten-free diet, with a positive clinical response. Conclusion: CD should be suspected in patients with SLE who present with diarrhea, abdominal pain, nausea/vomiting, recurrent oral aphthosis, and anemia. In rare seronegative CD cases, other causes of villous atrophy, mainly infectious, toxic, and immunological, must be ruled out. There is an association between CD and SLE, so diagnosis must be early and timely with the best testing scheme available to achieve effective treatment before complications occur.

Objetivo: Describir la presentación clínica y diagnóstico de un episodio de hipocalcemia grave en un paciente con lupus eritematoso sistémico (LES) en remisión, con diarrea crónica que condujo al diagnóstico de enfermedad celíaca (EC). Presentación del caso: Paciente de 22 años, con diagnóstico de LES a los 10 años, en remisión. Consultó por 2 meses de evolución de parestesias, espasmos musculares, mialgias y episodios de tetania en la semana previa, asociado a diarrea posprandial malabsortiva. Sus laboratorios mostraron hipocalcemia grave, déficit de vitamina D, hipomagnesemia grave e hipopotasemia leve. En el estudio para EC la serología reportó antitransglutaminasa tisular IgA, antigliadina IgA e IgG normales y niveles de IgA total bajos. La enteroscopia evidenció bulboduodenitis erosiva, con atrofia de las vellosidades y aumento de linfocitos intraepiteliales en la patología, que junto al estudio inmunohistoquímico permitieron concluir el diagnóstico de EC, tipo Marsh 3a. Se inició el manejo con una dieta libre de gluten, con una respuesta clínica positiva. Conclusión: La EC debe sospecharse en pacientes con LES que inicien con diarrea, dolor abdominal, náuseas/vómitos, aftosis oral recurrente y anemia. En los casos de EC seronegativa, los cuales son poco comunes, se deben descartar otras causas de atrofia de las vellosidades principalmente infecciosas, tóxicas e inmunitarias. Existe una asociación entre EC y LES, por lo cual el diagnóstico debe ser precoz y oportuno con el mejor esquema de pruebas disponible para lograr realizar un tratamiento efectivo antes de que se presenten las complicaciones.

Laryngotracheal Stenoses Post-Acute Respiratory Distress Syndrome due to COVID-19: Clinical Presentation, Histopathological Findings and Management. A Series of 12 Cases.

Coronavirus disease 2019 (COVID-19) has increased the risk of developing severe acute respiratory distress syndrome and subsequent moderate to severe laryngotracheal stenoses (LSTs) with an early presentation that occurs between two and three months after SARS-CoV-2 infection. We present a series of 12 cases of LST following SARS-CoV-2 infection. Dense lymphocyte infiltration with multinuclear giant cell granulomas was found on biopsy with intranuclear inclusions, suggestive of viral cytopathic effects in one case and intravascular fibrin thrombi with perivascular mononuclear infiltrate of CD3 + T lymphocytes. We present the largest and only series that describes clinical and histopathological characteristics of LTS and the management and outcomes after early laryngotracheal reconstruction in the context of the SARS-CoV-2 outbreak.

Espectro clínico de la enfermedad relacionada con IgG4 en Colombia / Clinical spectrum of IgG4-related disease in Colombia

RESUMEN La enfermedad relacionada con IgG4 es una condición inflamatoria sistémica, caracterizada por la infiltración de diversos órganos por complejos formados por células plasmáticas IgG4 positivas, asociadas con niveles elevados de IgG4 en el suero. El diagnóstico de esta enfermedad es complejo y los hallazgos clínicos no son patognomónicos. En esta serie de casos, describimos un amplio espectro clínico en 4 pacientes, en quienes, después de descartar otros diagnósticos, se confirmó la enfermedad relacionada con IgG4. A pesar de que esta enfermedad no es común, se debe considerar entre los diagnósticos diferenciales de enfermedades con afectación de múltiples órganos. Este reporte de pacientes con enfermedad relacionada con IgG4, en Colombia, resalta un amplio espectro de presentaciones clínicas, incluyendo estenosis subglótica, pancreatitis autoinmune, fibrosis retroperitoneal y compromiso sistémico.

ABSTRACT IgG4-related disease is an inflammatory systemic condition noted by the infiltration of different organs by IgG4-bearing plasma cells, as well as elevated serum IgG4 levels. Diagnosis of this condition is complex, and clinical findings are not particularly indicative. In this case series, a description is presented on 4 patients with a wide spectrum of clinical manifestations, in whom, after ruling out different options, a diagnosis of IgG4 related disease was confirmed. Despite this disease not being common, it should be considered among the options whenever multiple organs are affected. This report of patients with IgG4-related disease in Colombia highlights a wide spectrum of clinical presentations, including subglottic stenosis, autoimmune pancreatitis, retroperitoneal fibrosis, and systemic compromise.

Low-Grade, Nonintestinal Nonsalivary Sinonasal Adenocarcinoma Associated With an Exophytic Schneiderian Papilloma: A Case Report.

Sinonasal adenocarcinoma is a rare tumor of the head and neck accounting for 10% to 20% of all primary malignancies of the nose and paranasal sinuses. There tumors are classified as salivary, intestinal and nonintestinal, nonsalivary. Low-grade nonintestinal nonsalivary are rare tumors whose diagnosis is essentially that of exclusion. Here we present the first case of one such tumor associated with an exophyic Schneiderian papilloma. A 71-year-old retired aerospace engineer presented with a 1-year history of severe nasal obstruction. Endoscopy and compted tomography imaging demonstrated a polypoid lesion occupying his entire right nasal cavity extending into and filling the nasopharynx. Biopsy suggested adenocarcinoma, at least in situ and the patient subsequently underwent complete resection. Pathologic evaluation demonstrated polypoid tumor consistent with a low-grade papillary adenocarcinoma with micropapillary architecture associated with a small amount of residual exophytic Schneiderian papilloma. Immunohistochemistry revealed diffuse expression of CK7, CK 5/6, and S100 protein in tumor cells. Expression of p63 was seen in basal cells only. Tumor cells did not show expression of CK20, CDX2 (intestinal markers), mammaglobin, GATA3 (salivary markers), PAX8, WT1, nor estrogen, progesterone, or androgen receptors confirming its nonintestinal nonsalivary differentiation.

Aplicación de los Tissue Microarrays en el estudio inmunohistoquímico de los tumores / Applying Tissue Microarrays in tumor immunohistochemistry studies

Los tissue microarrays (TMAs) hacen posible agruparmás de 1.000 tumores en una sola laminilla, y ser utilizadospara el análisis de numerosos marcadores de interés diagnóstico,pronóstico o de ayuda en la decisión terapéutica yselección de estudios moleculares. Así hace posible ladetección y estudio de DNA y RNA (por hibridación in situo FISH) y proteínas (inmunohistoquímica).El objetivo de este estudio fue comprobar la representatividadde los TMAs en el estudio morfológico de diferentestumores y valorar los TMAs como herramienta para elestudio inmunohistoquímico. Los TMA se realizaron enadenocarcinomas de pulmón, adenocarcinomas de colon,carcinomas escamosos y oat-cell pulmonares, en el HospitalUniversitario Central de Asturias. Pudimos comprobarque los TMAs con tres cilindros por cada caso, son representativosdel tumor, tanto cuantitativamente como cualitativamente.La utilización de esta técnica tiene grandes ventajas quehacen posible efectuar un estudio en un tiempo escaso. Ellose halla motivado por una rápida velocidad en el procesamientode las muestras, la posibilidad de análisis simultáneoy estandarizado de múltiples muestras y la existencia de unárea de tamaño suficiente para analizar

Tissue microarrays (TMAs) allow the congregation ofmore than 1000 tumors in a single microscope slide. It canbe used for diagnostic and/or prognostic biomarker analysisthat permits the evaluation of therapeutic strategies or selectionof molecular studies. The TMAs allow the detection ofDNA and RNA by fluorescent in situ hybridization and proteindetection by immunohistochemistry.The purpose of this study was to evaluate the ability ofTMAs to differentiate tumors in morphologic studies and toassess the potential of the TMAs as a tool for immunohistochemistry.The TMAs were performed in lung adenocarcinoma,colon adenocarcinoma, squamous carcinomas andlung oat-cell carcinoma. The study was carry out on theHospital Universitario Central de Asturias in Spain. Wefound that 3 cylinder cuts of each sample provided a quantitativeand qualitative representation of each tumor. Thequick processing time of the samples, the ability to analyzemultiple samples at the same time, and wide area for analysisare the advantages of this technique. In conclusion theTMAs is a promising tool for investigation that will help ingetting results in a shorter period of time

Freshwater microorganisms and other arthropods in Papanicolaou smears.

Several types of contaminants have been reported in cytopathology. The purpose of this study was to show unusual contaminants in cytological smears, such as freshwater microorganisms and other arthropods. In different routine Papanicolaou smears (sputum, cervicovaginal, and voided urine) we mainly found fragments of mites and insects, caused by an intrinsic contamination of the samples or an extrinsic contamination of the smears.

Contaminantes poco habituales en extendidos de esputos / Uncommon contaminants of sputum smears

Planteamiento: Describir una serie de contaminantes a través de la observación microscópica de extendidos citológicos de esputos. Material y métodos: Extendidos de esputos coloreados mediante la técnica de Papanicolaou. Resultados: Hemos constatado, en 15.000 muestras de pacientes ingresados con diferentes patologías respiratorias durante los últimos 10 años, la presencia de diferentes tipos de microalgas, células vegetales, granos de polen y diversos cristales. Conclusiones: La existencia de contaminantes, en extendidos de esputos, es un hecho relativamente frecuente, teniendo un cierto significado biológico y debiéndose establecer en ocasiones su diagnóstico diferencial, dadas las similitudes con otras estructuras tales como hongos y diversos protozoos (AU)