Diffuse Small Intestine Erosions and Ulcers in an Immunocompromised Host

Gastrointestinal Histoplasmosis: A Descriptive Review, 2001-2021

Gastrointestinal histoplasmosis (GIH) is infrequently described in people without underlying HIV infection. We aimed to compare the clinical presentation of GIH in people with and without HIV infection. We conducted a literature search of published cases of GIH from 2001-2021 and found 212 cases. Of these, 142 (67.0%) were male, and 124 (58.5%) had HIV infection. Most cases were from North America (n = 88, 41.5%) and South America (n = 79, 37.3%). Of the 212 cases, 123 (58.0%) were included in both clinical and pathological analyses. The remainder were excluded as details about clinical and pathological findings were not available. Of the 123 cases, 41 had HIV infection while 82 were without HIV infection. The diagnosis was predominantly by histopathology (n = 109, 88.6%). A significant proportion of people with HIV infection had abdominal pain as the most predominant symptom of GIH compared to those without HIV infection (65.9% versus 41.9%, p < 0.05). The colon was the most affected site with a slightly higher proportion in those with HIV infection compared with cases without HIV infection (46.3% versus 42.7%). The commonest pathologic findings were caecal and ileal ulcers. Caecal ulcers were significantly more frequent in cases with HIV infection compared to those without HIV (32.1% versus 7.1%, p < 0.05). Despite being more common in people with HIV infection, GIH also affects people without HIV infection with similar clinical presentations.

Colonic Infection by Histoplasma capsulatum in a Liver Transplant Patient: A Case Report

Histoplasmosis is an infection caused by the dimorphic fungus Histoplasma capsulatum. While the lungs are the most common site of infection, disseminated disease affecting multiple organs can occur, particularly in immunocompromised patients. Gastrointestinal histoplasmosis is usually diagnosed in the context of disseminated disease and can present in any part of the digestive system, the ileum being the most frequently affected. We report the case of a 60-year-old female patient who underwent liver transplant for alcoholic liver cirrhosis. The patient had a 10 mm polypoid lesion in the sigmoid colon diagnosed in a screening colonoscopy performed 8 months prior to the transplant, but biopsy was not done for fear of bleeding due to extensive anorectal varices. There were no other lesions in the rest of the colon at that time. Four months after the transplant, the patient was asymptomatic and was submitted to a control colonoscopy, which showed 8 polypoid lesions in different parts of the colon, all of which were biopsied. Histologic results showed extensive infiltration of the colonic mucosa by Histoplasma capsulatum. Imaging and laboratorial screening for other sites of infection was negative, and the patient was treated with itraconazole for 12 months. A marked reduction in the dose of tacrolimus was necessary to maintain therapeutic levels during itraconazole treatment. Asymptomatic isolated colonic histoplasmosis is an uncommon manifestation of infection by Histoplasma capsulatum, with no previous reports in the literature of this condition affecting liver transplant recipients. This manuscript is compliant with the Helsinki Congress and the Istanbul Declaration.

Small bowel ulcers: when is it not inflammatory bowel disease ?

PURPOSE OF REVIEW

Increasing use of small bowel endoscopy unravels ulcers in a relevant number of patients. Although often attributed to inflammatory bowel disease (IBD), these ulcers may be unspecific or caused by a variety of other diseases. This review summarizes the recent literature related to differential diagnosis of small bowel ulcers.

RECENT FINDINGS

NSAID enteropathy is the major differential diagnosis to IBD in patients with small bowel ulcers. Intestinal tuberculosis must be considered in patients at risk. Rare causes for small bowel ulcers are autoinflammatory, neoplastic, vascular diseases, or nontuberculous infections. Morphology of small bowel ulcers cannot provide a reliable differentiation, and even histology is not specific in all cases. History with special focus on NSAID medication and clinical symptoms not typical for IBD, laboratory tests in the search of systemic disease, and microbiologic testing of biopsies can be helpful. Genetic testing allows identification of few rare entities like defects in prostaglandin metabolism.

SUMMARY

Due to a massive overlap in the endoscopic appearance of small bowel ulcers between possible causes, diagnosis should be based on broad information also including history, histology, imaging, and laboratory tests.