Acute generalised exanthematous pustulosis (AGEP) is a rare cutaneous eruption, most often caused by commonly used antibiotics. It is characterised by an acute onset of non-follicular sterile pustular rash and erythema within hours or days of drug exposure and usually resolves spontaneously within 1–2 weeks once the drug is discontinued. Haemodynamic involvement in the form of shock is rare. Here, we present a severe case of AGEP, manifesting with systemic involvement and haemodynamic instability resulting in shock with multiorgan dysfunction. The associated drugs were erythromycin and fluconazole with a possible combined effect of these two drugs that resulted in systemic involvement. Our patient improved markedly, both haemodynamically and dermatologically, after discontinuation of the drugs and with systemic steroid therapy.
INTRODUCTION:
We present a rare case of Ectopic Liver (EL) tissue along the pancreatic tail, that developed into HCC. Based on our research, there are only 4 reported cases of primary HCC in EL tissue around the pancreas. Our case originates in the retroperitoneum near the pancreas.
CASE DESCRIPTION/METHODS:
70 y.o Female with Tuberous Sclerosis was referred for an incidental finding of an abdominal mass. She was seen by her PCP for back pain and difficulty ambulating. Physical exam showed chronic facial rash. Abdominal exam was negative for a palpable mass, tenderness, guarding or rebound. Labs revealed normal LFTs and normocytic anemia. Viral hepatitis panel was negative. MRI abdomen showed a 6.8 × 7 cm mass in the LUQ with a central cystic cavity and a surrounding solid component.The mass abuted the pancreatic tail and loops of bowel and was of unclear origin. EUS showed a normal appearing pancreas. A hypoechoic mass with cystic and solid components was noted next to the pancreas. FNA was performed. Immunohistochemical staining was positive for Hepatocyte specific antigen (HSA), supporting hepatic origin and CK7 highlighting the presence of a bile ductules. This supported the diagnosis of hepatic tissue. Surgical resection was recommended. A 8 cm mass involving the splenic vein and pancreatic tail was noted and distal pancreatectomy and splenectomy was performed. Surgical pathology showed carcinoma with hepatic differentiation, most consistent with primary HCC, adherent to the pancreas, but not involving the pancreatic parenchyma. No benign liver tissue was identified. A diagnosis of HCC arising within and replacing a rest of ectopic liver was made. AFP post-op was normal. Post-op course was uneventful.
DISCUSSION:
EL is defined as liver tissue found outside and not in communication with the normal liver. It is susceptible to same diseases as normal liver and especially prone to malignancy, despite the lack of risk factors. Given the difference in arteriovenous and bile system, EL tissue may have longer exposure to carcinogens. MRI shows "post contrast peripheral solid enhancement" - suggestive of HCC with ectopic tissue enhancement in arterial phase, however is less highlighted compared to HCC in normal liver. AFP is > 20ng/mL in 60% cases. Surgical resection is the primary treatment with no reported tumor recurrence. Our case highlights the importance that any EL is at high risk for HCC development, despite the lack of risk factors and negative FNA biopsies and surgical therapy needs to be offered.
INTRODUCTION:
PEG tube has become the modality of choice for providing access for long term enteral nutrition. Despite a good safety record, complications due to PEG dislodgment do occur. We present a case of PEG tube causing Choledo-duodenal fistula, presenting with Ascending Cholangitis. To the best of our knowledge, this unusual complication of PEG tube hasn't been described before.
CASE DESCRIPTION/METHODS:
38 y.o.male with anoxic brain injury, PEG tube placed 6 months ago, presented for evaluation of Jaundice. Vitals were BP 145/108 | Pulse 135 | Temp 101.5 °F. On exam, patient had jaundice, abdomen was soft, Non tender, PEG tube was in the LUQ and Murphy’s sign was negative. Labs showed WBC 12 10X3 U/L, AST 46 U/L, ALT 131 U/L, TB 2.2 mg/dL, DB 1.1 mg/dL. CT abdomen and Pelvis revealed intrahepatic, extrahepatic and CBD dilatation to 1.2 cm, normal Pancreas. PEG tube with fluid-filled balloon was at the level of the pylorus or proximal duodenum. Small and large bowel were nondilated. The diagnosis of ascending cholangitis was made and ERCP was performed. ERCP showed the PEG tube balloon in the duodenum. It was repositioned into the stomach and the scope was advanced to the 2nd portion of the duodenum. There was a large white base ulcer at the duodenal sweep extending into the 2nd portion of the duodenum. Occlusion cholangiogram showed extravasation of the contrast from the distal CBD into the duodenal ulcer. There was a fistulous tract between the CBD and the ulcer. Sphincterotomy was made and a biliary stent was placed to heal the fistula. Biospy of the ulcer showed small intestinal mucosa with ulceration, fibrinoid exudates and no malignancy. Repeat ERCP 8 weeks later for stent removal, showed a chronic entero-biliary fistula.
DISCUSSION:
Our case is unique in that, this is the first CD fistula described in the literature as a complication of PEG tube presenting with ascending cholangitis. We hypothesize that the inflated balloon migrated into the duodenum due to gastric peristalsis and got incarcerated into the duodenum. 90% cases of CD fistula are due to impacted stone in the distal CBD. Other causes are Ampullary carcinoma or Cholangiocarcinoma. Based on our literature review, this is the only reported case of CD Fistula resulting from dislodged PEG tube causing direct pressure necrosis of the duodenal mucosa leading to erosion and fistulation with the distal CBD. Our case brings to light a new and potentially avoidable complication of PEG tubes.
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