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June Acute liver failure and severe hemophagocytosis se

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Ca<strong>se</strong> Snippet<strong>se</strong>sophagus in the terminal ileum. Report of a ca<strong>se</strong>. ArqGastroenterol 1985;22:79-82.5. Miller G, Boman J, Shrier I, Gordon PH. Small-bowel obstruction<strong>se</strong>condary to malignant di<strong>se</strong>a<strong>se</strong>: an 11-year audit.Can J Surg 2000;43:353-8.Correspondence to: Dr Tulasi. E-mail: nrtulasi@rediffmail.comReceived <strong>June</strong> 12, 2004. Accepted September 11, 2004<strong>Acute</strong> <strong>liver</strong> <strong>failure</strong> <strong>and</strong><strong><strong>se</strong>vere</strong> <strong>hemophagocytosis</strong><strong>se</strong>condary to parvovirus B19 infectionUsha Dutta, Sahil Mittal,*Radha Kanta Ratho, + Ashim Das**Departments of Gastroenterology, *Internal Medicine,+Virology <strong>and</strong> **Histopathology, Postgraduate Institute ofMedical Education <strong>and</strong> Re<strong>se</strong>arch, Ch<strong>and</strong>igarh 160 012Parvovirus infection pre<strong>se</strong>nting as <strong><strong>se</strong>vere</strong><strong>hemophagocytosis</strong> is extremely rare. We report a 13-year-old girl with acute parvovirus infection who had<strong><strong>se</strong>vere</strong> <strong>hemophagocytosis</strong> resulting in <strong><strong>se</strong>vere</strong> pancytopenia<strong>and</strong> hepatic <strong>failure</strong>. [Indian J Gastroenterol2005;24:118-119]Parvovirus infection is rare, usually mild, nonfatal,<strong>and</strong> affects children less than five years ofage. 1 It has been found to be associated with erythemainfectiosum, mild hepatitis, aplastic anemia, hydropsfetalis, abortions, <strong>and</strong> rarely <strong>hemophagocytosis</strong>. 2,3A 13-year-old girl pre<strong>se</strong>nted with low-grade intermittentfever of one-month duration. Four days after theon<strong>se</strong>t of fever, she noticed a maculopapular rash over thetrunk, which spontaneously resolved. She also noticedinsidious on<strong>se</strong>t of painless progressive non-cholestaticjaundice. Fifteen days later she developed ascites, bleedingfrom multiple sites, progressive pallor, <strong>and</strong> alterationof <strong>se</strong>nsorium. Past, personal <strong>and</strong> family history was noncontributory.On examination, she was febrile, pale, icteric,toxic, with evidence of mucocutaneous bleeding.Abdominal examination revealed 3-cm firm, nontenderhepatomegaly with moderate ascites <strong>and</strong> no splenomegaly.Rest of the systemic examination was unremarkable.Investigations showed pancytopenia (hemoglobin5.1 g/dL, leukocyte count 300/mm 3 , platelet count 80,000/mm 3 ). Liver function tests showed conjugated hyperbilirubinemia(31 mg/dL, direct 17), elevated <strong>se</strong>rum transamina<strong>se</strong>s(AST/ALT 51/67 IU/dL; N


Ca<strong>se</strong> SnippetsMost parvovirus infections are benign <strong>and</strong> <strong>se</strong>lflimited<strong>and</strong> do not require specific therapy. Patientswith parvovirus-induced fulminant hepatitis do betterthan tho<strong>se</strong> due to other etiology. 5 In <strong><strong>se</strong>vere</strong> infection,immunoglobulins, anti-thymocyte globulins,<strong>and</strong> anti-lymphocyte globulins have been tried withsome success. 6 It is es<strong>se</strong>ntial to perform <strong>se</strong>rology todetect acute parvovirus infections among patientswho pre<strong>se</strong>nt with pancytopenia, <strong>hemophagocytosis</strong><strong>and</strong> acute <strong>liver</strong> dysfunction.References1. Kishore J, Kapoor A. Erythrovirus B19 infection in humans.Indian J Med Res 2000;112:149-64.2. Hoang MP, Dawson DB, Rogers ZR, Scheuermann RH,Rogers BB. Polymera<strong>se</strong> chain amplification of archival materialfor Epstein-Barr virus, cytomegalovirus, human herpesvirus6 <strong>and</strong> parvovirus B19 in children with bone marrow<strong>hemophagocytosis</strong>. Hum Pathol 1998;29:1074-7.3. Yoto Y, Kudoh T, Ha<strong>se</strong>yama K, Suzuki N, Chiba S. Humanparvovirus B19 infection associated with acute hepatitis.Lancet 1996;347:868-9.4. Huang F, Arceci RJ. Histiocytosis. In: Rudolph CD, RudolphAM, Hostetter MK, Lister G, Siegel NJ, Eds. Rudolph’sPediatrics, 21st ed. New York: McGraw-Hill. 2002: p.1624-7.5. Sokal EM, Melchior M, Cornu C, V<strong>and</strong>enbroucke AT, ButsJP, Cohen BJ, et al. <strong>Acute</strong> parvovirus B19 infection associatedwith fulminant hepatitis of favourable prognosis inyoung children. Lancet 1998;352:1739-41.6. Rerolle JP, Helal I, Morelon E. Parvovirus B19 infectionafter renal transplantation. Nephrologie 2003;24:309-15.Correspondence to: Dr Dutta, Asstt Professor. Fax: (172) 2744401. E-mail: ushad@satyam.net.inReceived <strong>June</strong> 16, 2004. Accepted September 12, 2004Primary esophageal T-cellnon-Hodgkin’s lymphomaMathew K George, V Ramach<strong>and</strong>ran,S G Ramanan, T G SagarDepartment of Medical Oncology, Cancer Institute, Adyar,Chennai 600 036Primary non-Hodgkin’s lymphoma of the esophagusis a rare di<strong>se</strong>a<strong>se</strong>. We report a 52-year-old man whohad a polypoid mass in the esophagus at endoscopy.Histology was suggestive of non- Hodgkin’s lymphoma;immunohistochemistry was positive for CD3, CD45RO, LCA. He was treated with 6 cycles of CHOP <strong>and</strong>is di<strong>se</strong>a<strong>se</strong>-free 14 months later. [Indian J Gastroenterol2005;24:119-120]Approximately 98% of esophageal malignantneoplasms are squamous cell carcinomas, withthe remaining almost exclusively adenocarcinomas.Esophageal involvement by non-Hodgkin’s lymphoma(NHL) is unusual. The gastrointestinal system is thecommonest extranodal site of involvement of malignantlymphoma, the incidence ranging from 4%-20%. 1NHL primarily involving the esophagus is limitedto a few reports. It is described as primaryesophageal when only the esophagus or possibly thesatellite nodes are involved, in the ab<strong>se</strong>nce of distaladenopathy, infiltration of other organs, <strong>and</strong> synchronousinvolvement of other gastrointestinal sites. 2A 52-year-old gentleman had complaints of dysphagia<strong>and</strong> fever with loss of weight of 10 Kg, over threemonths. The patient had no history of acid-peptic di<strong>se</strong>a<strong>se</strong>,celiac di<strong>se</strong>a<strong>se</strong> or any immunodeficiency state. Physicalexamination was normal. Indirect laryngoscopy was normal.Fiberoptic endoscopy of the esophagus revealedprominent mucosal folds with a polypoid mass <strong>and</strong> anirregular growth in the lower end of the esophagus extendingfrom 35 cm from the incisor teeth to the esophagogastricjunction. Stomach <strong>and</strong> duodenum up to the <strong>se</strong>condpart were normal. Histology of the lesion showeddiffu<strong>se</strong> infiltration of the esophageal squamous mucosa<strong>and</strong> underlying muscle bundles by large round cells withmoderate cytoplasm, large dark hyperchromatic nucleus,<strong>and</strong> multiple prominent nucleoli; 0-2 mito<strong>se</strong>s were <strong>se</strong>enper high power field. This picture was suggestive of NHL– diffu<strong>se</strong> large cell type. Stain for Helicobacter pyloriwas negative.ESR was 40 mm in 1st hour <strong>and</strong> lactate dehydrogena<strong>se</strong>level was 450 u/mL; ELISA for human immunodeficiencyviral antigen was negative. CT scan showed smallposterior mediastinal lymph nodes 1-1.5 cm in size extendingalong the drainage of the esophagus; the abdomen<strong>and</strong> pelvis were normal. Examination bynasopharyngoscopy <strong>and</strong> colonoscopy did not show anylesion. Immunohistochemical study of the biopsy sampleshowed positive staining for CD3, CD45, RO, LCA, <strong>and</strong>negativity for CD20, CD30, CD15, EMA <strong>and</strong> keratin, suggestingan aggressive T-cell NHL.The patient was started on combination chemotherapywith cyclophosphamide, vincristine <strong>and</strong> prednisolone. Fever<strong>and</strong> dysphagia subsided <strong>and</strong> after two weeks he wastreated with st<strong>and</strong>ard CHOP regime. After four cycles ofchemotherapy, CT scan of the thorax was normal <strong>and</strong>esophagoscopy did not reveal any residual lesion. Thepatient received six cycles of chemotherapy with CHOPregime <strong>and</strong> achieved complete remission. He also receivedexternal beam radiotherapy of 40 Gy to the esophagus<strong>and</strong> draining nodal regions <strong>and</strong> is free of di<strong>se</strong>a<strong>se</strong> 14 monthslater.Primary gastrointestinal NHL constitutes 50%of extranodal pre<strong>se</strong>ntations. Stomach is the commonestorgan affected, followed by the small bowel.Primary involvement of the esophagus is extremelyrare, <strong>and</strong> only about a dozen ca<strong>se</strong>s have been reportedin literature. Almost 90% of lymphomas involvingthe esophagus are non-Hodgkin’s in type; inIndian Journal of Gastroenterology 2005 Vol 24 May - <strong>June</strong> 119

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