Severe hypoproteinemia as a harbinger of Ménétrier's disease in autoimmune pancreatitis.

Ménétrier's disease is an extremely rare disease of unknown etiology causing gastric mucosal hypertrophy and protein-losing gastropathy. Rare cases of this condition have been reported in patients with autoimmune diseases. However, to the best of our knowledge, Ménétrier's disease associated with autoimmune pancreatitis (AIP) has never been reported. We described a case of severe hypoproteinemia as a harbinger of Ménétrier's disease associated with AIP. The patient was successfully treated with octreotide and high-protein diet, which led to symptomatic remission and significant improvement in serum levels of albumin and recovery of the nutritional status. Thus, in AIP patients presenting with severe and persistent hypoproteinemia without apparent cause, clinicians need to consider Ménétrier's disease in the differential diagnosis. In this setting, endoscopic evaluation with histological examination of gastric biopsy material, including a full-thickness mucosal biopsy of involved mucosa, may be helpful in promptly establishing the diagnosis and allowing appropriate and timely therapy.

Severe hypoproteinemia as a harbinger of Ménétrier's disease in autoimmune pancreatitis / Hipoproteinemia grave como indicador de doença de Ménétrier na pancreatite autoimune

Summary Ménétrier's disease is an extremely rare disease of unknown etiology causing gastric mucosal hypertrophy and protein-losing gastropathy. Rare cases of this condition have been reported in patients with autoimmune diseases. However, to the best of our knowledge, Ménétrier's disease associated with autoimmune pancreatitis (AIP) has never been reported. We described a case of severe hypoproteinemia as a harbinger of Ménétrier's disease associated with AIP. The patient was successfully treated with octreotide and high-protein diet, which led to symptomatic remission and significant improvement in serum levels of albumin and recovery of the nutritional status. Thus, in AIP patients presenting with severe and persistent hypoproteinemia without apparent cause, clinicians need to consider Ménétrier's disease in the differential diagnosis. In this setting, endoscopic evaluation with histological examination of gastric biopsy material, including a full-thickness mucosal biopsy of involved mucosa, may be helpful in promptly establishing the diagnosis and allowing appropriate and timely therapy.

Resumo A doença de Ménétrier é uma condição extremamente rara, de etiologia desconhecida, caracterizada por hipertrofia da mucosa gástrica e gastropatia perdedora de proteína. Casos raros dessa patologia têm sido relatados em pacientes com doenças autoimunes. Até o momento, desconhecemos qualquer relato dessa doença associada à pancreatite autoimune (PAI). Descrevemos um caso de hipoproteinemia grave como indicador de doença de Ménétrier associada à PAI. O paciente foi tratado de forma satisfatória com octreotide e dieta hiperproteica, alcançando remissão sintomática, melhora significativa das concentrações de albumina e recuperação do estado nutricional. Portanto, em pacientes com PAI e hipoproteinemia grave e persistente, deve-se considerar a doença de Ménétrier como um diagnóstico diferencial. Nesses casos, a avaliação endoscópica com biópsia gástrica, incluindo biópsia de toda a espessura da mucosa, pode ser útil no estabelecimento do diagnóstico e do pronto início da terapêutica.

Enfermedad de Crohn y eritema nudoso: ¿es útil la nutrición enteral exclusiva? / Crohn's disease and erythema nodusum: Is exclusive enteral nutrition useful?

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Peeling skin syndrome: Current status.

Peeling Skin Syndrome (PSS) is a rare genodermatoses characterized by asymptomatic, localized or generalized, continuous exfoliation of the stratum corneum; it may present at birth or in adulthood. We describe a patient having the type A non-inflammatory variant of PSS showing asymptomatic and continuous skin peeling from the neck, trunk, back, and extremities. Friction appeared to be an aggravating factor, but there was no seasonal variation. Histopathology in this condition reveals hyperkeratosis and splitting of the epidermis between the granular layer and the stratum corneum. No treatment for this disorder has been found to be effective so far.

[Hypereosinophilic syndrome with the esophagus, stomach and small intestine pathology].

In this article the differential diagnostic line of blood hypereosinophilia is analyzed and the complicated clinical case of severe eosinophilic esophagogastroenteritis with recurrent oedema associated with protein loss is represented.

[A rare cause of peripheral edema: exudative lymphocytic gastritis induced hypoprotidemia]. / Une cause rare d'oedèmes: l'hypoprotidémie de la gastrite lymphocytaire exsudative.

Diagnosis of edema secondary to hypoprotidemia but without nutritional, renal, hepatic or cardiac cause, must consider exudative digestive disease, of which the lymphocytic gastritis, as the authors report here a new observation diagnosed in a 73 year-old woman. Gastroscopy reveals varioliform gastritis and biopsy demonstrates diffuse infiltration of the gastric epithelium by lymphocytes, making of it a real histopathologic entity among the gastropathies. Etiology and pathogeny remain still unknown but proton pump gastric inhibitors are an effective treatment.

[Congenital intestinal lymphangiectasia: a rare differential diagnosis in hypoproteinemia in infants]. / Kongenitale intestinale Lymphangiektasie: Eine seltene Differerenzialdiagnose hypoproteinämischer Odeme im Säuglingsalter.

BACKGROUND: Congenital intestinal lymphangiectasia is a rare disease in childhood, which may already cause protein-losing enteropathy in newborns. PATIENT, METHODS AND RESULTS: This is a case report of an infant with generalized edema and protein-losing enteropathy, in whom intestinal lymphangiectasia was diagnosed at the age of two months. Following repetitive intravenous albumin und gamma globulin infusions, the elimination of long-chain fats from the diet and the substitution with medium-chain triglycerides (MCT) led to an improvement of the protein-losing enteropathy. CONCLUSION: In newborns with low level of serum protein and edema protein-losing enteropathy caused by congenital lymphangiectasia might be considered as a differential diagnosis.

Familial hypercatabolic hypoproteinemia caused by deficiency of the neonatal Fc receptor, FcRn, due to a mutant beta2-microglobulin gene.

Two siblings, products of a consanguineous marriage, were markedly deficient in both albumin and IgG because of rapid degradation of these proteins, suggesting a lack of the neonatal Fc receptor, FcRn. FcRn is a heterodimeric receptor composed of a nonclassical MHC class I alpha-chain and beta(2)-microglobulin (beta(2)m) that binds two ligands, IgG and albumin, and extends the catabolic half-lives of both. Eight relatives of the siblings were moderately IgG-deficient. From sera archived for 35 years, we sequenced the two siblings' genes for the heterodimeric FcRn. We found that, although the alpha-chain gene sequences of the siblings were normal, the beta(2)m genes contained a single nucleotide transversion that would mutate a conserved alanine to proline at the midpoint of the signal sequence. Concentrations of soluble beta(2)m and HLA in the siblings' sera were <1% of normal. Transfection assays of beta(2)m-deficient cultured cells with beta(2)m cDNA indicated that the mutant beta(2)m supported <20% of normal expression of beta(2)m, MHC class I, and FcRn proteins. We concluded that a beta(2)m gene mutation underlies the hypercatabolism and reduced serum levels of albumin and IgG in the two siblings with familial hypercatabolic hypoproteinemia. This experiment of nature affirms our hypothesis that FcRn binds IgG and albumin, salvages both from a degradative fate, and maintains their physiologic concentrations.

Clinical heterogeneity of neonatal intrahepatic cholestasis caused by citrin deficiency: case reports from 16 patients.

A deficiency of citrin, which is encoded by the SLC25A13 gene, causes both adult-onset type II citrullinemia (CTLN2) and neonatal intrahepatic cholestasis (NICCD). We analyzed 16 patients with NICCD to clarify the clinical features of the disease. Severe intrahepatic cholestasis with fatty liver was the most common symptom, but the accompanying clinical features were variable, namely; suspected cases of neonatal hepatitis or biliary atresia, positive results from newborn screening, tyrosinemia, failure to thrive, hemolytic anemia, bleeding tendencies and ketotic hypoglycemia. Laboratory data showed elevated serum bile acid levels, hypoproteinemia, low levels of vitamin K-dependent coagulation factors, and hypergalactosemia. Hypercitrullinemia was detected in 11 out of 15 patients examined. Most of the patients were given a lactose-free and/or medium chain triglycerides-enriched formula and lipid-soluble vitamins. The prognosis of the 16 patients is going fairy well at present, but we should observe these patients carefully to see if they manifest any symptom of CTLN2 in the future.

Dysproteinemia and the kidney.

Dysproteinemia is a clinical state characterized by abnormal, often excessive, synthesis of immunoglobulin (Ig) molecules or subunits. Dysproteinemia results from clonal proliferation of plasma cells or B lymphocytes. The abnormal circulating Ig molecules or subunits (most commonly free light chains) reach the glomerulus via the systemic circulation and are associated with the development of a variety of pathologic lesions within the kidney. Free light chain molecules may pass through the glomerular basement membrane and form casts within distal tubular lumina (myeloma cast nephropathy) or form crystals within the cytoplasm of proximal tubules (light chain Fanconi syndrome). Alternatively, Ig molecules or subunits may form paraprotein tissue deposits and produce an array of pathologic lesions, most commonly amyloidosis and monoclonal Ig deposition disease. The pattern of renal parenchymal disease is determined by the unique properties of the Ig molecule or subunit. Each of the patterns of renal disease is in turn associated with unique, but frequently overlapping, clinical features and outcomes. This review emphasizes the pathologic, clinical, and prognostic differences among the patterns of renal parenchymal disease related to dysproteinemia.

Utilization of knockout mice to examine the potential role of gastric histamine H2-receptors in Menetrier's disease.

Menetrier's disease is characterized by giant gastric folds with foveolar hyperplasia and cystic dilatation, hypoproteinemia, and enhanced mucus secretion. The etiology remains unresolved and an effective treatment has yet to be established. Here we show that histamine H(2)-receptor deficient mice developed gastric pathophysiological changes resembling Menetrier's disease for up to 17 months of observation. Mutant mice were found to have an increased stomach weight, enlarged gastric folds with cystic dilatation, hypergastrinemia, hypoalbuminemia, increased mucus secretion and overexpression of mucosal transforming growth factor (TGF) alpha. Both a cholecystokinin (CCK)(2)-receptor antagonist and an epidermal growth factor (EGF)-receptor tyrosine kinase inhibitor significantly reduced the increase in stomach weight. It appears that lack or downregulation of histamine H(2)-receptors might be involved in the pathogenesis of Menetrier's disease.

A case of toxic shock-like syndrome presenting with serious hypoproteinaemia because of a protein-losing gastroenteropathy.

A 37-year-old man was admitted to our hospital because of toxic shock-like syndrome (TSLS) induced by Streptococcus pyogenes. After the pathogenic bacteria had been eradicated, serious diarrhoea appeared and a protein-losing gastroenteropathy developed. An immunohistochemical study of the biopsy specimens of both small and large intestines revealed the infiltration of T-lymphocytes, predominantly CD8+ cells, into the lamina propria of affected mucosa, villus atrophy and crypt hyperplasia. Considering these histological findings, some immunological mechanism which lead the activation of cytotoxic T-lymphocytes may play an important role in the pathogenesis of this rare intestinal manifestation of TSLS.

Intestinal crypt lesions associated with protein-losing enteropathy in the dog.

Six dogs were diagnosed with protein losing enteropathy (PLE). There was no evidence of inappropriate inflammatory infiltrates or lymphangiectasia in multiple mucosal biopsies of the small intestine of 4 of the dogs. The 5th and 6th dogs had obvious lymphangiectasia and a moderate infiltrate of inflammatory cells in the intestinal mucosa. All 6 dogs had a large number of dilated intestinal crypts that were filled with mucus, sloughed epithelial cells, and/or inflammatory cells. Whether PLE occurs in these dogs because of protein lost from the dilated crypts into the intestinal lumen or whether the dilated crypts are a mucosal reaction due to another undetermined lesion that is responsible for alimentary tract protein loss is unknown. However, when large numbers of dilated intestinal crypts are present, they appear to be associated with PLE even if there are no other remarkable lesions in the intestinal mucosa.

Ménétrier's disease evaluated serially by abdominal ultrasonography.

We report the case of a 3-year-old boy with Ménétrier's disease who presented with prominent anasarca associated with hypoproteinemia, but no proteinuria. An early sonogram of the stomach demonstrated thickening of the gastric wall which was found to resolve gradually on serial sonograms. Consequently, we considered that the submucosal layer of the gastric wall was particularly thickened as a result of Ménétrier's disease. A gastric biopsy was performed 18 days after onset of the disease, and an electron-microscopic examination of the sample disclosed persistent widening of gastric tight junctions by more than 10 nm. The patient made a full recovery on supportive treatment in 3 weeks. Ultrasonography provided us with a potent tool not only in making the diagnosis, but also in following the course of the disease.

[Therapy-refractory primary intestinal lymphangiectasis]. / Therapierefraktäre primäre intestinale Lymphangiektasie.

A 20-year-old man with severe physical weakness (from which he soon recovered spontaneously) was found to have hypoproteinaemia and lymphocytopenia (768/microliters). Ten years later, after having been free of symptoms in the meantime, oedema, ascites and abdominal pain occurred, associated with loss of physical capacity. Enteric loss of protein (alpha 1-antitrypsin clearance increased about thirtyfold) with a total serum protein concentration of only 3.7 g/dl, as well as histological evidence of lymphangiectasia of the small and large intestines provided the diagnosis of primary intestinal lymphangiectasia. In the course of the disease cholelithiasis and (after treatment with tranexamic acid) thrombosis of the axillary vein occurred. No treatment has been of any avail and the patient has been unable to work for three years.

Congenital myotonic dystrophy with progressive edema and hypoproteinemia.

We report a patient with congenital myotonic dystrophy who had progressive edema and hypoproteinemia. An atrioseptal defect and patent ductus arteriosus were noted and were considered to be the cause of the right heart failure and edema. Although urinary protein levels were minimal, infusion of albumin did not improve the hypoproteinemia. Administration of dexamethasone increased the serum protein level, but the edema was not ameliorated. Autopsy revealed a slight lymphatic dilation in the small intestine, suggesting protein-losing enteropathy.

Landing disease, GM1 generalized gangliosidosis, and malabsorption syndrome.

A case of beta galactosidase deficiency is described in a 20-month-old boy. The child was hospitalized at 4 months of age for malabsorption syndrome. Biopsies of the small intestine and liver were performed and electron microscopy of the liver specimens strongly suggested a gangliosidosis. The cytoplasm of macrophages, Kupffer cells and hepatocytes contained membrane-bound lysosomes with a granular, fibrillar appearance and tubular structures interpreted as ganglioside deposits. Enzymatic deficiency was confirmed by biochemical investigation of leukocytes from both the patient and members of his immediate family. Although visceromegaly is typical of Landing disease, symptoms of malabsorption and hypertension have not been reported in its course.

A case of Ménétrier's disease accompanied by severe hypogammaglobulinemia.

We describe a case of Ménétrier's disease accompanied by severe hypoproteinemia with marked decrease of gamma globulin. Roetogenograms and endoscopic findings of the upper gastrointestinal tract demonstrated enlarged gastric rugae and multiple small protuberances of the duodenal mucosa. Histological findings a gastric biopsy specimens showed mucosal thickening and hypertrophy. Plasminogen activator activities were increased in both gastric and jenunal mucosal biopsy specimens. Severe hypoproteinemia was proven by the Gordon test and by determination of protein content of gastric juice to be due to protein loss into the gastric lumen.