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Phlegmonous gastritis: case report A 44-year-old woman with rheumatoid arthritis developed phlegmonous gastritis during immunosuppressive therapy with leflunomide and adalimumab. The woman, who had been receiving leflunomide [Arava; dosage not stated] since June 2000, started receiving additional adalimumab [Humira; dosage not stated] in February 2003. About 6 years after leflunomide initiation, she underwent stomach and small intestine biopsies. Shortly after the biopsy, she presented with a 6-hour history of sudden onset diffuse abdominal pain, and was admitted for acute abdomen. She had rebound tenderness in all four abdominal quadrants, pale skin and an impalpable peripheral pulse. Her BP was 90/60mm Hg, her HR was 135 beats/min and her body temperature was < 36°C. Laboratory investigations revealed a WBC count of 3300/µL, a C-reactive protein level of 25 mg/dL and a serum lactate level of 10.3 mmol/L. Abdominal CT scan showed marked thickening of the gastric wall and free abdominal fluid. About 1L of a cloudy ascite were released during laparotomy. Mesentery cultures grew streptococci group A. Intraoperative gastroscopy revealed laminar erosions covered by a fibrinous film and haemorrhages. Histology revealed mildly florid antral gastritis. Tissue necrosis was limited to the inner layers of the stomach wall. The woman started receiving meropenem and vancomycin. Benzylpenicillin [penicillin G] was added to her therapy when culture results were obtained, and high dose pantoprazole was administered for mucosal necrosis. Under intensive care, she slowly recovered over the next 8 weeks. Sequential repeat gastroscopies revealed sloughing of almost the entire gastric mucosa. Her stomach had completely re-epithelized 8 months later, but endoscopy also showed an antral stricture. She did not experience further abdominal symptoms apart from a postprandial feeling of fullness. Author comment: It can be speculated if a previous biopsy, as in this case, constitutes a big enough entry point for streptococci in immunocompromised patients. Scheppach W, et al. Phlegmonous gastritis in a 44-year-old woman on immunosuppressive therapy. Deutsche Medizinische Wochenschrift 132: 1567-1570, No. 30, 27 Jul 2007 [German] - Germany

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Reactions 3 Nov 2007 No. 1176