Clinicopathologic Conference

Abstract

A 60-year-old man was admitted to King Faisal Specialist Hospital and Research Centre because of fever and back pain.He had a three-year history of pain in the right leg radiating to the back with associated poor appetite and weight loss. Four months before being admitted to this Hospital, he was seen at another hospital. Examination there revealed a palpable right lower quadrant mass that was firm, round, and fixed. He had a mildly enlarged liver and chest x-ray was normal. Results from a barium enema indicated a possible lesion of the cecum and ascending colon.One month after admission to the first hospital, an exploratory laparotomy was done, and the patient was thought to have a locally advanced, inoperable carcinoma of the cecum. The doctors performed a side-to-side ileotransverse colostomy, without biopsy, and he was transferred to King Faisal Specialist Hospital.Upon admission the patient was thin, somewhat dehydrated, and febrile. His temperature was 38 °C, weight 41kg, and vital signs were normal. There was an ill-defined mass in the right iliac fossa. The rest of the examination was normal. White blood count 5500; hemoglobin 11.2g/dl; sedimentation rate 54mmHg/h; albumin 3.0g/dl (normal-5.0g/dl); and total protein 7.8g/dl (normal-8.0g/dl). Liver function studies were all within normal limits. Serum sodium was slightly decreased at 134meq/l (normal-145meq/l); electrolytes were otherwise within normal limits. Electrocardiogram was normal. A chest x-ray, done prior to admission, showed a slightly irregular radio-opaque density in the apex of the left lung that seemed to be an old, calcific nodule. A barium enema series was done and the results showed an undistended cecum with an irregular mucosal pattern and marked narrowing in the cecal region. There was no reflux of barium into the ileum. Test findings strongly indicated carcinoma of the cecum and ascending colon. The oncologist at King Faisal Specialist Hospital was not able to determine the type and extent of the tumor. Another laparotomy was deemed necessary in order to assess the extent and histology of the tumor.One week after admission to the Hospital a diagnostic laparotomy was performed. The surgeon reported extensive seeding of small deposits on the surface of the peritoneum throughout the pelvis and over the liver. Two masses were found, one in the cecum and the other in the right portion of the transverse colon. The peritoneum was studded with innumerable two to four millimeter white nodules such as those in tuberculous implants or adenocarcinoma. Biopsies revealed confluent granulomatous inflammation consistent with tuberculosis; a number of biopsy specimens were examined.One day following surgery, the patient was started on isoniazid, 150mg IMq 12h and streptomycin, 300mg IMq 12h. Three days later the medication was changed to isoniazid, 300mg PO/day, ethambutol, 600mg PO/day, and rifampicin, 600 mg PO/day, with pyridoxine cover. He was discharged on these medications and followed as an outpatient.The patient's initial clinical response was...

Gastrointestinal Manifestation of Kaposi's Sarcoma: A Case Report and Review of Literature

“…8 Only one case with gastrointestinal lesion has so far been reported from Saudi Arabia. 9 The majority of patients are in the fifth through eighth decades of life, and a ratio of 10-15 males to each female has been reported. 10 Our patient was a female in her fifth decade.…”