Fulminant liver failure and pancreatitis associated with the use of sulfamethoxazole-trimethoprim

We report the case of a 26-yr-old patient with fulminant liver failure and acute hemorrhagic pancreatitis secondary to the use of trimethoprim-sulfamethoxazole (Bactrim DS). Our patient presented with skin rash and decreased C3 and C4 levels, which we believed was due to a hypersensitivity reaction secondary to the sulfonamide component (sulfamethoxazole). To our knowledge, this is the first case reported in which sulfamethoxazole-trimethoprim has been implicated as a cause of fulminant liver failure and acute hemorrhagic pancreatitis simultaneously, and emphasizes the need of discontinuing this medication as soon as there is evidence of liver and pancreatic dysfunction.

Fulminant idiopathic pseudomembranous colitis

Pseudomembranous colitis is characterized by inflammatory plaques and pseudomembranes on the colonic mucosa. The disorder most commonly occurs after the use of antibiotics, which allow overgrowth of Clostridium difficile, a spore-forming, gram-positive rod that produces a toxin. Overgrowth of Staphylococcus aureus can also produce pseudomembranous colitis. In rare cases, pseudomembranous colitis is not associated with antibiotic use. When C. difficile is present, vancomycin or metronidazole usually produces a prompt response. In idiopathic cases, surgery may be required.

Large hypopharyngeal polyp producing intermittent dysphagia and acute airway obstruction

A 65-yr-old man who developed sudden respiratory arrest was found to have a long, smooth, esophageal filling defect on esophagogram. Endoscopy eventually proved this to be a large esophageal polypoid lesion that had arisen in the hypopharynx and extended to the midesophagus. He was successfully treated with a lateral pharyngotomy and excision of the hypopharyngeal polyp.

Elevated levels of immunoglobulins and immune complexes in the bile of patients with primary sclerosing cholangitis

The concentration of immunoglobulins and immune complexes was determined in the serum and bile of four patients with primary sclerosing cholangitis, only one of whom had chronic ulcerative colitis, and in four postcholecystectomy control patients. The result of the immunoglobulin studies demonstrated increased serum levels of IgM in primary sclerosing cholangitis as compared to control patients. The IgG, IgA, and IgM in bile were all significantly elevated as compared to controls (p = 0.02). Immune complexes in bile and serum were also determined in both groups by the C1q and conglutinin binding assays. Immune complexes in bile were elevated in three of four of the patients with primary sclerosing cholangitis. These findings further characterize primary sclerosing cholangitis in terms of biliary immunoglobulins and immune complexes but do not resolve whether these changes are an epiphenomenon or reflect a primary role of immunoglobulins and immune complexes in the pathogenesis of this disorder.

Primary sclerosing cholangitis associated with massive intraabdominal lymphadenopathy

A 40-year-old man with a history of insulin-dependent diabetes mellitus was admitted to the hospital because of jaundice and pruritus. During his evaluation the diagnosis of primary sclerosing cholangitis and "microscopic" ulcerative colitis were established. Massive intraabdominal lymphadenopathy was discovered on CT scan and histological examination eventually proved this to be follicular hyperplasia. The case herein reported documents the association of primary sclerosing cholangitis with diabetes mellitus and ulcerative colitis as well as reporting the occurrence of massive intraabdominal lymphadenopathy.

Ileocecal histoplasmosis mimicking Crohn's disease in a patient with Job's syndrome

A 16-years-old male with a history of Job's syndrome and a recent diagnosis of Crohn's disease was admitted to the hospital because of abdominal pain, nonbloody diarrhea, weakness, and fever. Due to failure to respond to medical therapy it was decided that an operation was indicated, and resection of the terminal ileum and right colon was performed. Cecum and ileum were inflamed, and pathologic studies revealed the presence of budding yeasts which on special stain were diagnostic of Histoplasma species. Successful management was accomplished with oral ketoconazole.

Intracholedochal irrigation with saline through a nasobiliary catheter: an adjunct to endoscopic sphincterotomy in the treatment of large stones in the common bile duct

A 54-year-old woman with multiple abdominal operations including cholecystectomy and partial small bowel resection was admitted to the hospital because of pain in the right upper quadrant. Multiple common bile duct stones-the largest one measuring approximately 2 cm-were seen during endoscopic retrograde cholangiogram. The patient was successfully treated with endoscopic sphincterotomy and placement of a nasobiliary catheter for intracholedochal irrigation with a saline solution.

Mirizzi syndrome

A 56-year-old woman was admitted to the hospital because of icterus and pruritus of 1 month duration. During her evaluation, endoscopic retrograde cholangiography revealed large cystic duct stones causing partial obstruction of the common hepatic duct. Successful management was accomplished with choledochojejunostomy and T-tube decompression. The case herein reported illustrates the typical clinical presentation and radiographic features of the Mirizzi syndrome.

Cholecystoduodenal fistula

An elderly woman with a history of cholelithiasis was seen for right upper quadrant pain and jaundice. During her evaluation, she was found to have extensive choledocholithiasis and a cholecystoduodenal fistula. Successful management was accomplished with cholecystectomy, removal of the common bile duct stones, and by creating a choledochoduodenostomy where the fistula had been present.

Multiple gastric carcinoids in a patient with a history of primary hyperparathyroidism

A 66-year-old man with a past history of hyperparathyroidism was evaluated for chronic epigastric pain. An upper gastrointestinal x-ray examination revealed the presence of polypoid filling defects and endoscopy-polypectomy eventually proved these to be gastric carcinoids.

Intraluminal duodenal diverticulum

A 46-year-old woman was seen for evaluation of dyspepsia of 8-wk duration. X-rays of the upper gastrointestinal tract revealed an intraluminally projecting diverticulum of the duodenal bulb. Diagnostic features and management of intraluminal duodenal diverticulum are reviewed.

Primary sclerosing cholangitis

Primary sclerosing cholangitis is a chronic, cholestatic disease affecting the biliary tree. Recent data suggest an autoimmune etiology. Clinical findings, roentgenographic characteristics, and compatible liver histology will help in establishing the diagnosis. There is no known treatment for cure, though relief of symptoms may be accomplished with certain drugs, such as antibiotics for cholangitis and cholestyramine for pruritus. Death usually ensues within five to seven years after diagnosis, as a consequence of liver failure, cholangitis, and cholangiocarcinoma.

Primary sclerosing cholangitis occurring in a patient with systemic lupus erythematosus and diabetes mellitus

A 42-year-old woman with a longstanding history of systemic lupus erythematosus and insulin-dependent diabetes mellitus was admitted to the hospital because of icterus, anorexia, pruritus, and weight loss of 3 months duration. During her evaluation the diagnosis of primary sclerosing cholangitis was established. The following case documents the unusual association of systemic lupus erythematosus and insulin-dependent mellitus with primary sclerosing cholangitis.

Focal nodular hyperplasia associated with the use of a synthetic anabolic androgen

An adolescent with stunted growth was treated for 6 months with a synthetic anabolic androgen. During his evaluation for right upper quadrant pain an abnormal liver scan demonstrated what proved to be a hypervascular hepatic lesion. At surgery, the diagnosis of focal nodular hyperplasia was established. Herein we document the unusual association of focal nodular hyperplasia with use of a synthetic anabolic androgen.

Successful medical management of a Yersinia enterocolitica liver abscess

An insulin-dependent diabetic patient with liver abscess secondary to Yersinia enterocolitica without septicemia is described. He had the diagnosis established by transhepatic needle aspiration of the abscess cavity. Successful management was accomplished with antibiotic therapy alone.

Pyogenic liver abscess

The primary source of pyogenic liver abscess is undetermined in about 30 percent of cases. Escherichia coli, microaerophilic streptococci and Bacteroides fragilis are among the common pathogens. Some cases can be treated with antibiotics alone; others require surgical management. With improved methods of diagnosis and therapy, the mortality rate is now 10 percent or less.