Cronkhite-Canada syndrome with esophagus involvement and six-year follow-up: A case report

BACKGROUND

Cronkhite-Canada syndrome (CCS) is a rare, noninherited disease characterized by gastrointestinal polyposis with diarrhea and ectodermal abnormalities. CCS polyps are distributed through the whole digestive tract, and they are common in the stomach and colon but very uncommon in the esophagus.

CASE SUMMARY

Here, we present a case of a 63-year-old man with skin hyperpigmentation accompanied by diarrhea, alopecia, and loss of his fingernails. Laboratory data indicated anemia, hypoalbuminemia, hypocalcemia, hypokalemia, and positive fecal occult blood. Endoscopy showed numerous polyps scattered throughout the digestive tract, including the esophagus. He was treated with nutritional support and glucocorticoids with remission of his symptoms.

CONCLUSION

Comprehensive treatment led by hormonal therapy can result in partial or full remission of clinical symptoms. Treatment should be individualized for each patient according to their therapy response. Surveillance endoscopy is necessary for assessing mucosal disease activity and detecting malignant transformation.

The first report on effect of fecal microbiota transplantation as a complementary treatment in a patient with steroid-refractory Cronkhite-Canada syndrome: A case report

RATIONALE

Cronkhite-Canada syndrome (CCS) is a rare non-hereditary disease of unknown etiology that is characterized by the appearance of multiple polyps in the entire gastrointestinal (GI) tract, except in the esophagus, with GI and non-GI symptoms. Various factors are associated with the pathogenesis of CCS. Immune dysregulation has been discussed as one of the pathogeneses of CCS, and dysbiosis of the gut microbiota can affect the immune system. Currently, standard treatment has not been established.

PATIENT CONCERNS AND DIAGNOSIS

We present the treatment with fecal microbiota transplantation (FMT) in a 67-year-old male patient with steroid-refractory CCS who could not undergo anti-tumor necrosis factor-a treatment due to suspected tuberculosis infection.

INTERVENTIONS

FMT has recently attracted attention as a method of overcoming drug resistance through immunomodulatory effects through microbiome regulation. We collected the patient's stool samples before FMT and 8weeks after FMT.

OUTCOMES

We analyzed the microbiome composition of patients by sequencing the V3-V4 region of the 16s rRNA gene (Miseq). After FMT, the number of episodes of diarrhea and hypoalbuminemia were also corrected. The Chao 1 index after FMT, which was significantly higher than that of donors before FMT, changed to a similar level for donors after FMT. Fusobacterium nucleatum, Pyramidobacter piscolens, and Campylobacter concisus disappeared after FMT, suggesting the presence of an association between gut microbiota and CCS.

LESSONS

Furthermore, we provide the possibility that microbiome modulation by FMT could serve as a complementary treatment in patients with steroid-refractory CCS.

Cronkhite-Canada syndrome associated with perianal condyloma acuminatum with malignant transformation: A case report

RATIONALE

Cronkhite-Canada syndrome (CCS) is a rare non-familial polyposis syndrome characterized by multiple gastrointestinal polyps with the ectodermal triad. To date, many complications of CCS have been reported in the literature, but perianal condyloma acuminatum with malignant transformation has not been included.

PATIENT CONCERNS

This report presents the case of a 52-year-old Chinese man who presented with diarrhea, loss of appetite, and weight loss. He developed skin pigmentation and atrophy of the fingernails and toenails. Upper gastrointestinal endoscopy, colonoscopy, capsule endoscopy, and enteroscopy revealed diffuse polyps along the entire digestive tract. Histopathological examination revealed polyps of different pathological types dominated by hamartoma. Physical examination revealed a crissum cauliflower-like neoplasm (2.5 × 2.0 cm). After perianal tumor resection, pathology suggested that this was a perianal condylomatous lesion with malignant transformation, as well as well-differentiated squamous cell carcinoma.

DIAGNOSES

These clinical features and endoscopic findings were consistent with CCS which associated with perianal condyloma acuminatum with malignant transformation.

INTERVENTION

Clinical remission was achieved with glucocorticoid, azathioprine, and nutritional support.

OUTCOME

At the 4-year follow-up, the patient had no diarrhea or loss of appetite, had gained 13 kg in weight, and the perianal tumor had not recurred.

LESSONS

No previous report has described CCS in a patient with perianal condyloma acuminatum with malignant transformation. As both conditions are related to immune disorders, their occurrence may be correlated.

Guidelines for the management of hereditary colorectal cancer from the British Society of Gastroenterology (BSG)/Association of Coloproctology of Great Britain and Ireland (ACPGBI)/United Kingdom Cancer Genetics Group (UKCGG)

Heritable factors account for approximately 35% of colorectal cancer (CRC) risk, and almost 30% of the population in the UK have a family history of CRC. The quantification of an individual's lifetime risk of gastrointestinal cancer may incorporate clinical and molecular data, and depends on accurate phenotypic assessment and genetic diagnosis. In turn this may facilitate targeted risk-reducing interventions, including endoscopic surveillance, preventative surgery and chemoprophylaxis, which provide opportunities for cancer prevention. This guideline is an update from the 2010 British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland (BSG/ACPGBI) guidelines for colorectal screening and surveillance in moderate and high-risk groups; however, this guideline is concerned specifically with people who have increased lifetime risk of CRC due to hereditary factors, including those with Lynch syndrome, polyposis or a family history of CRC. On this occasion we invited the UK Cancer Genetics Group (UKCGG), a subgroup within the British Society of Genetic Medicine (BSGM), as a partner to BSG and ACPGBI in the multidisciplinary guideline development process. We also invited external review through the Delphi process by members of the public as well as the steering committees of the European Hereditary Tumour Group (EHTG) and the European Society of Gastrointestinal Endoscopy (ESGE). A systematic review of 10 189 publications was undertaken to develop 67 evidence and expert opinion-based recommendations for the management of hereditary CRC risk. Ten research recommendations are also prioritised to inform clinical management of people at hereditary CRC risk.

[Two cases of the rare Cronkhite-Canada syndrome]

Cronkhite-Canada syndrome (CCS) is a rare non-heritable condition characterized by gastrointestinal polyposis, dysgeusia, malnutrition, total alopecia and onychodystrophia. Two Danish cases of CCS (an 88-year-old female and a 69-year-old male) presented with signs of malnutrition, dyspepsia, vomiting, dysgeusia and hair loss. An upper endoscopy revealed marked oedema and polyposis in the stomach. Both patients developed colonic adenocarcinomas which were radically operated. Treatment consisted of hyperalimentation, prednisolone and azathioprine. Both patients went into remission - the first patient totally.

Cronkhite-Canada syndrome: Report of six cases and review of literature

Cronkhite-Canada syndrome (CCS) is a rare nonfamilial polyposis syndrome characterized by epithelial disturbances in the gastrointestinal tract and skin. The aim of this study was to investigate the clinical features and potential therapies for CCS. Six patients with CCS admitted from December 1992 to July 2008 to Peking Union Medical College Hospital were evaluated. All patients had clinical manifestation of nonhereditary gastrointestinal polyposis with diarrhea, skin hyperpigmentation, alopecia, and nail dystrophy. Fecal occult blood was positive in all six cases. Serum hemoglobin, potassium, calcium and protein were below the normal range in two cases. Anti-Saccharomyces cerevisiae and antinuclear antibodies were present in three cases. Multiple polyps were found in all patients by gastroscopy and colonoscopy, with only one in the esophagus. Histologically, there were hyperplastic polyps in five cases, tubular adenoma in three, and juvenile polyp in one with chronic inflammation and mucosal edema. Comprehensive treatment led by corticosteroids can result in partial remission of clinical symptoms, and long-term follow-up is necessary.

18F-FDG PET/CT imaging for a gastrointestinal mantle cell lymphoma with multiple lymphomatous polyposis

Multiple lymphomatous polyposis (MLP) is an uncommon type of gastrointestinal lymphoma characterized by the presence of multiple polyps along the gastrointestinal tract. Most of this entity is in fact considered the counterpart of gastrointestinal tract involvement for mantle cell lymphoma (MCL). To our knowledge, there have been no reports on [fluorine-18]-fluorodeoxy-glucose (¹⁸F-FDG)-positron emission tomography (PET)/computed tomography (CT) imaging for gastrointestinal MCL with MLP. We present the results of ¹⁸F-FDG PET/CT imaging in a patient with gastrointestinal tract involvement of MCL showing continuous MLP from the stomach to the rectum and intestinal intussusception. FDG-PET/CT findings were false negative in typical MLP spreading widely over the gastrointestinal tract, but uptake was noted in large lesions with deep infiltration considered atypical as MLP. On FDG-PET/CT imaging, the Ki-67 proliferative index, which is a cell proliferation marker, showed neither correlation with the presence of uptake nor the maximum standardized uptake value.

[Digestive tract polyposes]

The article provides an overview of hereditary polyposis syndromes of the digestive tract and genetic mechanisms in greater detail. A brief summary of the basic symptoms of the condition, including extra gastrointestinal signs, is given. Significant diagnostic procedures are listed. The therapy for these disease conditions is either operative or endoscopic.

[Cronkhite-Canada syndrome - a rare intestinal polypotic syndrome]

Cronkhite-Canada syndrome is a rare polypotic disease of the gastrointestinal tract. There are no specific diagnostic criteria for this syndrome. Suspicion may arise if both an endoscopic and a histopathologic finding together with the patient's symptom picture are indicative of the disease. Other polypotic conditions should be excluded. No established treatment is available for the syndrome. The principles of treatment have remained almost unchanged at least over the past decade. With a large proportion of the patients eventually developing a gastrointestinal malignancy, the prognosis of the disease is mostly poor.

[Cronkhite-Canada syndrome is a rare polyposis syndrome]

Cronkhite-Canada syndrome (CCS) is rare and associated with diarrhoea, gastrointestinal polyps, malnutrition, weight loss, alopecia, skin- and nail changes. The patient was hospitalized with dehydration, diarrhoea and weight loss. Objectively emaciated, skin changes, poor nail status and alopecia. Biochemistry compatible with malnutrition. Gastroscopy showed polyps. Treatment of symptomatic replacement therapy and prednisolone resulted in remission. It is a diagnosis with a 55% 5-year mortality. Early treatment leads to better prognosis.

Case of Cronkhite Canada syndrome shows improvement with enteral supplements

Cronkhite-Canada syndrome (CCS) is a rare nonfamilial syndrome characterized by marked epithelial disturbances in the GI tract and epidermis. Cronkhite and Canada described the first 2 cases in 1955. Since then only about 450 cases have been reported worldwide. Here we report a 33 year old Indian male admitted with history of loose stools and abdominal pain, loose stools associated with weight loss, generalized weakness, significant amount of hair loss as well as hyperpigmentation of his palms and soles. On subsequent days of the stay in the hospital he developed hypogeusia and showed onychodystrophy. Endoscopy of Upper GI and Lower GI tract revealed severe gastroduodenitis with polyp in duodenum and multiple polyps whole throughout the colon respectively. Biopsy report showed eosinophilic gastritis and hamartomatous polyps in colon as well as in duodenum. He was started on high protein supplement, proton pump inhibitors and zinc-vitamin supplement and he showed a complete recovery in symptoms within 5 months of initiation of treatment. Hence, early diagnosis and initiation of appropriate treatment helped the patient to improve in symptoms from such a rare disease.

[Clinical characteristics of Cronkhite-Canada syndrome in Chinese: meta-analysis of 35 cases]

OBJECTIVE

To investigate the clinical characteristics of Chinese patients with Cronkhite-Canada syndrome (CCS).

METHODS

Relevant data of Chinese CCS patients from 1985 to 2006 were retrieved from Medline and Chinese biomedical database and a meta-analysis was conducted.

RESULTS

A total of 35 CCS cases had been reported by Chinese hospitals with the clinical characteristics of gastrointestinal polyposis with ectodermal trilogy, mainly manifested as diarrhea, bellyache, weight loss, anemia, and edema. Canceration was reported in 2 patients. Some patients had symptomatic response to combination therapy. There might be racial or regional differences in CCS susceptibility; however, such information was often neglected in the medical records at home and abroad. New techniques, such as (99)Tc(m)-HSA scan, double-balloon enteroscopy and wireless capsule endoscopy provided new information on CCS.

CONCLUSION

The clinical features of Chinese CCS patients are similar to those of the European or Japanese patients. Novel appliance, case report standardization and sharing database may promote the understanding of this rare syndrome.

Capsule endoscopy changes patient management in routine clinical practice

Our objective was to evaluate the diagnostic yield and effect of capsule endoscopy on patient management in routine clinical practice. Three hundred examinations were performed (176 females; mean age, 51 years), with a median follow-up of 17 months. Indications included overt bleeding (n=55), anemia (n=104), suspected Crohn's disease (n=68), celiac disease (n=35), suspected functional symptoms (n=23), polyposis (n=5), and miscellaneous (n=10). The overall diagnostic yield was 39%, but it was notably higher in overt bleeders, 66%, compared to 46% in the anemia group (P<0.025), 32% in the suspected Crohn's group (P<0.001), and 17% in the functional group (P<0.001). As a result of capsule endoscopy, management was altered in 26% of patients. This study shows that capsule endoscopy has both a high diagnostic yield and an impact on subsequent patient management. These data further support the role of capsule endoscopy in routine clinical practice.

Cronkhite-Canada syndrome associated with schizophrenia

Here, we report a case of Cronkhite-Canada syndrome in a patient with schizophrenia. A 64-year-old man, who had been diagnosed as having a schizophrenic disorder at the age of 30, presented with alopecia, atrophic nail changes, hyperpigmentation of the skin, and inflammatory polyposis of the stomach and colon. Endoscopic ultrasonography of the stomach and colon revealed diffuse mucosal thickening with small hypoechoic areas, corresponding to edema of the lamina propria. After treatment with parenteral hyperalimentation and tranexamic acid, his physical findings and polyposis gradually improved. This is the first report of Cronkhite-Canada syndrome in a patient with schizophrenia.