ABSTRACT Gastric linitis plastica is a diffusely infiltrative adenocarcinoma that characteristically spares the overlying mucosa, rendering standard forceps biopsies frequently nondiagnostic. We report a 26-year-old woman evaluated over 3 months for presumed inflammatory bowel disease (IBD), supported by an elevated fecal calprotectin and colonic wall thickening, in whom diffuse gastric thickening and low-serum-ascites albumin gradient (SAAG) ascites ultimately redirected the workup toward malignancy. After an initial nondiagnostic esophagogastroduodenoscopy (EGD) with superficial biopsies, diagnosis was established at repeat EGD by snare biopsy of the thickened gastric folds, which sampled submucosal tumor that forceps had missed. Histology demonstrated infiltrating poorly differentiated (poorly cohesive) adenocarcinoma, and staging confirmed peritoneal metastasis (stage IVB). The patient deteriorated rapidly with tumor-related bowel perforation before systemic therapy could begin. This case illustrates an under-recognized presentation of linitis plastica mimicking new-onset IBD in a young adult, highlights low-SAAG ascites as a pivotal diagnostic clue, and reinforces same-session escalation to deeper tissue acquisition when superficial biopsies are nondiagnostic despite high clinical suspicion.
ABSTRACT Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome often triggered by an underlying disease process. Macrophage activation syndrome (MAS) is a secondary HLH phenotype associated with autoimmune disease. A 72-year-old man presented with fever, pancytopenia, hyperferritinemia, splenomegaly, and acute liver injury. Bone marrow biopsy demonstrated hemophagocytosis, supporting HLH. Despite corticosteroid therapy, progressive liver injury prompted liver biopsy, which revealed sinusoidal hemophagocytosis and noncaseating granulomatous inflammation consistent with hepatic sarcoidosis. Infectious and malignant evaluations were unrevealing. This case highlights hepatic sarcoidosis as a rare underlying driver of secondary macrophage activation syndrome/HLH and the importance of tissue diagnosis in patients with severe hepatic involvement.
ABSTRACT Primary hepatic perivascular epithelioid cell tumor (PEComa) is a rare mesenchymal neoplasm that can mimic common hepatic malignancies. A 28-year-old African woman with colorectal cancer in remission presented with 3 months of epigastric pain and tender hepatomegaly. Tumor markers were normal. Ultrasound and triphasic CT showed 2 large heterogeneous hypervascular hepatic masses with progressive enhancement and early venous drainage; hepatobiliary iminodiacetic acid scan (HIDA) SPECT-CT demonstrated photopenic lesions. Biopsy revealed epithelioid cells with focal HMB45, diffuse smooth muscle actin, and Ki-67 20%–30%, confirming hepatic PEComa. Resection was feasible but deferred; everolimus was started before loss to follow-up.
ABSTRACT Dietary supplements are widely perceived as safe, yet high-dose ingestion can cause severe toxicity. We report a 20-year-old woman who developed acute hepatocellular injury following intentional ingestion of 15 g nicotinamide. She presented with vomiting, epigastric pain, and transient hypotension. Liver function tests rapidly deteriorated with a marked transaminitis, with associated coagulopathy. There was no hepatic encephalopathy. Extensive investigations for viral, autoimmune, metabolic, and vascular causes were unrevealing. She improved with supportive care, including N-acetylcysteine, vitamin K, and electrolyte replacement. This case highlights nicotinamide overdose as an important and potentially under-recognized cause of severe acute liver injury.
