A 60-year-male presented with progressively increasing dysphagia accompanied with loss of weight. He denied ingestion of corrosive or any medication. Upper gastrointestinal endoscopy revealed a nonnegotiable stricture at 32 cm from the incisors [Figure 1] and multiple endoscopic biopsies from the mouth of the stricture were noncontributory. Barium swallow confirmed the presence of lower esophageal stricture [Figure 2]. Contrast enhanced computed tomography revealed marked wall thickening of the esophagus at the site of narrowing [Figure 3]. High-frequency endoscopic ultrasound (EUS) at 20 MHz revealed marked thickening of the wall of the esophagus with the loss of wall stratification (maximum thickness 11.2 mm) [Figure 4]. No significant mediastinal lymph nodes were detected on EUS. Endoscopic bougie dilatation of the esophageal stricture was done, and the patient had transient improvement in dysphagia. Positron emission tomography revealed flourodeoxyglucose (FDG) avid esophageal wall thickening (SUVmax 2.3) [Figure 5]. No significant FDG uptake was observed anywhere else in the body. Because of the possibility of hidden malignancy, the patient underwent esophagectomy with gastric pull-up. The resected specimen revealed ulcerated esophageal mucosa and dense submucosal fibro-inflammatory reaction which had storiform pattern and IgG4 rich plasma cell infiltration [Figures 6 and 7]. Serum IgG4 levels done postoperatively were within normal limits. The patient had an anastomotic leak that was successfully managed with endoscopic dilatation and patient is asymptomatic at 8 months of follow-up.Figure 1: Upper gastrointestinal endoscopy: Nonnegotiable stricture in lower esophagusFigure 2: Barium swallow: Lower esophageal strictureFigure 3: Contrast enhanced computed tomography: Marked wall thickening of the esophagus at the site of narrowingFigure 4: High-frequency endoscopic ultrasound: Marked thickening of the wall of the esophagus with loss of wall stratificationFigure 5: Positron emission tomography-computed tomography: Flourodeoxyglucose avid esophageal wall thickening (SUVmax 2.3)Figure 6: Microphotograph: Fibro-inflammatory reaction with storiform pattern and plasma rich infiltrate (H and E, ×40)Figure 7: Immunohistochemistry: IgG4 rich plasma cells (×40)The IgG4 related disease usually involves pancreas with the involvement of biliary tract, salivary glands, lymph nodes, thyroid, kidneys, lung, skin, prostate, and aorta also reported in the literature.[12] Involvement of upper gastrointestinal tract by IgG4-related inflammatory cells is very rare and there are very few case reports describing IgG4-related esophageal disease with the majority of patients being treated with surgery.[234] In spite of rarity, IgG4 related esophageal disease should be considered in the differential diagnosis of unexplained esophageal strictures. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Herpes simplex encephalitis is the most common cause of sporadic viral encephalitis worldwide but presents as a diagnostic challenge at many settings due to its non-specific symptoms, which can be easily mistaken for systemic infection or metabolic encephalopathy. It has diverse range of presentations from fever, altered sensorium, nausea, vomiting, meningismus to seizures, neurological deficits and coma in advanced stages. It is associated with significant morbidity and mortality if treatment is delayed or inadequate. We here discuss a case of Herpes simplex virus (HSV) encephalitis which rapidly progressed to result in irreversible neurological insult due to delayed diagnosis and treatment.
Leiomyosarcomas of the mediastinum are rare tumours, with only four cases reported in the literature. In the absence of any specific clinical pointer for diagnosis, proof comes through histopathologic study. One case of leiomyosarcoma of the superior mediastinum is reported here because of its rarity and an interesting histopathology.
Vitamin B12 and folate deficiency are reversible causes of megaloblastic anemia. Strict vegetarians are at risk of megaloblastic anemia due to low cobalamin in their diet. Knuckle hyperpigmentation in patients with megaloblastic anemia is due to excess melanin synthesis in skin. Here we present a case of a young vegetarian male with megaloblastic anemia with knuckle hyperpigmentation managed successfully with intravenous followed by oral vitamin b12 and folate supplementation.
Introduction and Aim: Erosive reflux disease (ERD) and Non-erosive reflux disease (NERD) are common gastrointestinal (GI) diseases in primary healthcare facilities that might result in alterations in gastric microflora. The aim was to characterize the altered composition of the gastric microflora in both groups and their effects on normal metabolic pathways. Materials and Methods: A total of 27 individuals, consisting of 18 patients of ERD, 4 patients of NERD, and 5 controls based on the questionnaire data and clinical diagnosis. The gastric microbiome was sequenced using 16S rRNA next-generation sequencing. Gastric microbial diversity and compositions were analyzed using MicrobiomeAnalyst. Functional analysis was performed using PICRUST. Results: Dysbiosis was observed in both ERD and NERD groups when compared to the control. Alpha diversity was found to be significant at the ACE index, at the order (p = 0.0239) and class (p = 0.019) taxonomic levels. The gastric microbiome composition at the genus level of the study groups represented a significant decrease of Gram-positive bacterial genera such as Streptococcus, Corynebacterium, and Granulicatella along with an increase of Gram-negative genera such as Helicobacter and Veillonella. Significant alterations in the metabolic pathways due to this dysbiosis were also predicted for both groups. Conclusion: The alterations in the gastric microflora are caused by both ERD and NERD, these alterations are further associated with a shift in microbial consortia towards the abundance of gram-negative bacterial genera that might lead to the progression of GI diseases to a chronic state.
Enterococcus faecalis (Ef) is one of the major pathogens involved in hospital-acquired infections. It can cause nosocomial bacteremia, surgical wound infection, and urinary tract infection. It is important to mention here that Ef is developing resistance against many commonly occurring antibiotics. The occurrence of multidrug resistance (MDR) and extensive-drug resistance (XDR) is now posing a major challenge to the medical community. In this regard, to combat the infections caused by Ef, we have to look for an alternative. Rational structure-based drug design exploits the three-dimensional structure of the target protein, which can be unraveled by various techniques such as X-ray crystallography or nuclear magnetic resonance (NMR) spectroscopy. In this review, we have discussed the complete picture of Ef infections, the possible treatment available at present, and the alternative treatment options to be explored. This study will help in better understanding of novel biological targets against Ef and the compounds, which are likely to bind with these targets. Using these detailed structural informations, rational structure-based drug design is achievable and tight inhibitors against Ef can be prepared.
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