Massive hemorrhage caused by a perforating Gianturco-Z stent resulting in an aortoesophageal fistula.

Endoscopic placement of self-expanding metal stents is regarded as a safe and effective method of palliating obstructive esophageal malignancies. We report here the case of a 49-year-old woman with an inoperable squamous-cell carcinoma located in the mid-esophagus. After two courses of chemotherapy, a silicone-covered Gianturco-Z stent was placed because of progressive tumor growth. Eighteen days after the stent placement, the patient presented with hematemesis, and died 24 hours after admission. At autopsy, the proximal end of the stent was found to have perforated through the normal esophageal mucosa into the aorta, resulting in an aortoesophageal fistula. This complication should be considered in patients who present with massive hemorrhage after undergoing radiotherapy or chemotherapy, or both, before stent placement in the mid-esophagus.

Vasculitis attributed to the nicotine patch (Nicotinell).

Nicotine-containing patches are used to facilitate tobacco withdrawal by mitigating abstinence symptoms and diminishing craving. We describe two patients who developed vasculitis in association with the use of a nicotine patch. The first concerns a patient who developed fever, arthritis, a generalized erythema and purpuric lesions, after 3 days use of nicotine patches. Laboratory results and a skin biopsy confirmed the diagnosis of a leucocytoclastic vasculitis. After stopping use of the patch, the patient recovered. On challenge, the symptoms reappeared. The second patient developed purpuric lesions during the use of nicotine patches, and recovered fully after these were stopped. In these patients, nicotine patches seem to be causally related to the development of vasculitis.