Acute esophageal necrosis or black esophagus is an uncommon clinical entity, diagnosed at the upper gastrointestinal endoscopy with the presence of strikingly black necrotic esophagus. Very often no definite etiology will be identified even though a large list of potential associations has been postulated. Upper gastrointestinal bleeding is the most common clinical presentation, others being epigastric pain, retrosternal chest discomfort and dysphagia. Only about a hundred cases of acute esophageal necrosis have been described in medical literature till this date. We report a case of acute esophageal necrosis in an elderly female who had presented with hematemesis.

Isolated pancreatic tuberculosis (TB) remains a rarity despite the high incidence of tuberculosis in many of the African and Asian countries. Presentation as discrete pancreatic mass often masquerades as pancreatic neoplasm and diagnosis may require histology. Extra-hepatic portal hypertension due to splenic vein thrombosis complicating pancreatic TB has been reported in the literature. We report here a case of isolated pancreatic TB with pancreatic head mass mimicking neoplasm with extra-hepatic portal hypertension. The possibility of TB should be considered in the list of differential diagnoses of pancreatic mass and an endoscopic, ultrasound-guided biopsy might help to clinch the diagnosis of this potentially curable disease.

Coexistent diabetes mellitus increases the incidence of complications and hospitalizations in cirrhosis patients but without impact on mortality rates. There is no significant morbidity or mortality difference between cirrhotics with antecedent diabetes and hepatogenous diabetes.

W e report an unusual case of recurrent stroke in a patient with vitamin B 12 deficiency who was also homozygous for the methylene tetrahydrofolate reductase (MTHFR) gene mutation. The patient was a 35-year-old male vegetarian with no known medical history who initially presented with global aphasia, slurred speech, right facial weakness, and right-sided hemiplegia and was found to have a stroke (NIH Stroke Scale score of 25). At that time a CT scan of the head ruled out intracranial hemorrhage and a CT angiogram of the head and neck was done. The patient was found to have occlusion of the M1 segment of the left middle cerebral artery. Because he was within the time frame for thrombolytics, systemic thrombolysis with alteplase was given without improvement. He therefore underwent a cerebral angiogram that demonstrated occlusion of the M1 segment of the left middle cerebral artery and very poor leptomeningeal collaterals from the left anterior and posterior cerebral artery territories (figure 1). He underwent mechanical thrombectomy of the left middle cerebral artery thrombus with Penumbra aspiration device (Penumbra Inc., Alameda, CA) and SOLITAIRE stentriever (Covidien, Irvine, CA) with complete recanalization of the occluded segment (figure 2). He had a remarkable early recovery as the hemiplegia resolved. During the hospital course he was placed on a statin and low-dose aspirin and was later discharged to a rehabilitation unit for treatment of his right-sided hemiparesis and residual expressive aphasia. Workup for secondary stroke prevention, including telemetry and a transesophageal echocardiogram, was unremarkable.On follow-up MRI 3 months later, a small new acute left middle cerebral artery stroke was found. At that time he underwent a workup for a hypercoagulable state. The workup was negative for the following: lupus anticoagulant, anticardiolipin antibody, factor V Leiden mutation, prothrombin gene mutation, protein C and S deficiency, and antithrombin deficiency. However, the patient was found to have a markedly elevated homocysteine level of 55.7 mmol/L (normal 5-15 mmol/L) and relatively low levels of vitamin B 12 and folate at 206 ng/L (normal 180-914 ng/L) and 5.2 mg/L (normal $4 mg/L), respectively. Serum creatinine was 0.98 mg/dL and complete blood count showed hemoglobin of 14.4 g/dL and mean corpuscular volume of 88 fL. Genetic testing revealed the presence of homozygous MTHFR 677 TT genotype.The patient was then treated with supplemental vitamin B 12 1,000 mcg daily, initially IM and then orally. He also received folic acid supplementation. Two months later, the patient's symptoms improved dramatically, with resolution of his expressive aphasia and marked improvement of his right-sided hemiparesis. Laboratory data also showed improvement, as Practical ImplicationsIn certain patients with recurrent stroke, such as those with elevated homocysteine and MTHFR gene mutations, supplemental vitamin B 12 may be beneficial.

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Bleeding manifestations, usually cutaneous or gastrointestinal - are common in liver cirrhosis. Spontaneous intracerebral and intramuscular bleeds are reported uncommonly, often associated with gross hepatic dysfunction and severely deranged hemostatic parameters, and are often markers to imminent mortality. Male sex, alcoholic etiology, significant thrombocytopenia, severe coagulopathy, and advanced liver disease are common denominators in patients with spontaneous intramuscular bleed. We here report three cases of spontaneous muscle hematomas complicating hepatic cirrhosis. To the best of our knowledge, this is the largest single center series reporting spontaneous muscle hematomas complicating cirrhosis from the Indian subcontinent.

Pseudo-Ludwig's phenomenon, an exceedingly rare clinical entity, is characterized by non-infectious upper airway obstruction resulting from spontaneous hematoma in the sublingual space. The condition is often described in patients on anticoagulants with grossly deranged coagulation profile. We describe a case of pseudo-Ludwig's phenomenon in a cirrhotic patient with significantly deranged hemostasis profile; the first to be reported in medical literature.

Sweet's syndrome is an uncommon dermatosis and can be associated with a wide variety of illnesses including infections and malignancies. Sweet's syndrome as a dermatological manifestation in human immunedeficiency virus (HIV) infection is rarely reported. Furthermore, called acute febrile neutrophilic dermatosis is characterized by fever and skin lesions, which are often erythematous papules and pseudovesicles. Diagnosis is based on clinical features and histology. The gold standard for treatment is systemic steroids although many other medications have been tried with variable success. We here report a case of Sweet's syndrome in an HIV-infected patient.