Management of cytomegalovirus reactivation in patient with immunotherapy-induced gastritis.

We present the case of a 52-year-old woman diagnosed with stage IV clear cell renal cell carcinoma who received combination of surgery and systemic therapy with nivolumab (anti-PD1) and ipilimumab (anti-CTLA-4). During treatment, patient presented oral intolerance, vomiting and abdominal pain. Computed tomography (CT) and gastroscopy (EGD) were performed, identifying findings suggestive of severe gastro-duodenitis with friability and diffuse oedema of the mucosa and deep ulcers. A gastrointestinal immunotherapy-induced toxicity was suspected so patient was managed with proton pump inhibitors (PPIs) and intravenous corticosteroids 1mg/Kg. Three weeks later, corticosteroid treatment failed. EGD was repeated and gastric biopsies were taken for histological and microbiological tests. Gastric biopsies revealed the presence of cytomegalovirus (CMV) inclusion bodies by immunohistochemistry (IHC). CMV viral load by quantitative PCR in plasma was 2,000 IU/mL so intravenous ganciclovir was prescribed. Then, the patient presented poor clinical course with persistent vomiting due to a failure of first-line corticosteroid and antiviral treatment. Another EGD was performed. Last IHC reveals a low CMV viral load. Second-line treatment with Anti-TNF was performed using a single-dose regimen of intravenous infliximab 5 mg/Kg. Finally, the patient presented a clinical and endoscopic response and a negative CMV DNA test in the blood after completing the antiviral treatment.

Hernia de Morgagni en el adulto como causa de obstrucción intestinal / Morgagni hernia as the cause of intestinal obstruction in an adult

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An unexpected cause of dysphagia: pleural mesothelioma.

Malignant mesothelioma usually originates from the pleura or peritoneum, and has a poor prognosis. The incidence of this type of tumor is increasing worldwide, which is probably a result of occupational or environmental exposure to asbestos. In 90% dyspnea, chest pain or a combination of both are usually the initial symptoms. Dysphagia only occurs in 1.4% and is very rare as the initial symptom. We present the case of a middle-aged patient, in whom the initial symptom was dysphagia, so an endoscopy was performed. This showed extrinsic compression of the esophagus that was demonstrated when performing the chest X-ray, in which it was revealed a posterior mediastinal mass surrounding the esophagus concentrically without mucosal invasion.

Enfermedad de Whipple: cuando la diarrea está ausente / Whipple's disease: when diarrhea is absent

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Una causa inesperada de disfagia: mesotelioma pleural / An unexpected cause of dysphagia: pleural mesothelioma

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Whipple's disease: when diarrhea is absent.

Whipple's disease is a rare bacterial, chronic and multisystemic disease, produced by the gram-positive bacillus Tropheryma whipplei. The clinical manifestations are varied and diagnosis is often delayed. The four cardinal symptoms are arthralgias, weight loss, diarrhea and abdominal pain. The classic symptoms could be preceded up to three quarters by different joint manifestations that evolve intermittently. The average time to diagnosis is 6 years. We present the case of a young patient with recurrent febrile episodes and associated joint disease, in whom the absence of digestive symptoms led to a diagnostic laparoscopy since this entity was not suspected before.

Síndrome del ligamento arcuato medio como causa de angina intestinal / Median arcuate ligament syndrome as a cause of intestinal angina

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Fístula colecistocutánea / Cholecystocutaneous fistula

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Median arcuate ligament syndrome as a cause of intestinal angina.

Median arcuate ligament syndrome (MALS) or celiac artery compression syndrome is caused by extrinsic compression by the median arcuate ligament. It is often asymptomatic, but it can cause intestinal symptoms suggestive of angina. We present a patient with repeated episodes of postprandial pain, nausea and occasional vomiting. After several studies, it was concluded that the symptomatology was attributable to this syndrome. Conservative treatment was performed due to the coexistence of underlying neoplastic disease and low life expectancy.

Cholecystocutaneous fistula.

Spontaneous external biliary fistula or cholecystocutaneous fistula is defined as the rupture of the gallbladder through all layers of the abdominal wall, with development of a fistulous tract to the skin without prior biliary surgery or trauma. We report the case of an octogenarian woman with debilitating comorbidities and consequently immunosuppression who presented with spontaneous external biliary fistula and a history of ERCP three months before, a procedure that was carried out with no apparent immediate complications.

Invaginación yeyuno-yeyunal en paciente con malrotación intestinal / Jejuno-jejunal invagination in a patient with intestinal malrotation

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Metástasis gástrica por melanoma / Metastatic melanoma of the stomach

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Fractura de fémur en un paciente con enfermedad de Paget poliostótica / Fracture of the femur in a patient with polyostotic Paget's disease

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Infección diseminada por Mycobacterium bovis tras instilación intravesical de bacilo de Calmette-Guérin / Disseminated infection due to Mycobacterium bovis after intravesical instillation of bacillus Calmette-Guérin

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Leiomiomatosis multinodular esofágica: una causa infrecuente de masa mediastínica / Multinodular esophageal leiomyomatosis: An uncommon cause of mediastinal mass

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