Clinico-pathological Conference
Clinical Discusser: Amir Mirbagheri MD
Pathological Discusser: Masoud Sotoudeh MD
Moderator: Leily Eslami MD
Tuesday 87-11-1, 12:30-13:30 pm
Shariati Hospital, Shaheed Payrovian Hall
A 54 Y/O lady was consulted for evaluation of longstanding heartburn. She had suffered from acid regurgitation, heartburn and chest pain since six years ago. She had referred to a gastroenterologist who performed an upper GI endoscopy, told her that she has GERD and started her on omeprazole. She had partial improvement and her omeprazole was increased to twice daily without any further benefit. Two years ago she underwent another upper GI endoscopy which revealed raised 10mm ulcers in mid- and lower esophagus and the repor concluded as GERD-B with ulcers (LA classification). She was switched to Pantozole 40 mg per day but her hearburn and chest pain persisted. Addition of Baclofen 10 mg thrice daily did not improve her condition as well. She was told that she has intractable GERD.
Her past medical history included eight years history of progressive dyspareunia and vaginal discharge. Initially she was treated with oral and local antibiotics but her condition did not improve. Four years ago she was diagnosed with vaginal stenosis and underwent surgical correction of her condition. Post-operatively her dyspareunia and vaginal discharge recurred and she was treated with several courses of antibiotics in vain. Prior to that she had an episode of deep vein thrombosis for which she received intravenous heparin followed by oral Coumadin for a few months. Three years ago she was told that she may have Behcet’s disease because of recurrent oral lesions and was started on oral prednisolone which was gradually tapered to five mg per day and continued till her recent presentation. Her vaginal discharge and dyspareunia continued. An infectious disease specialist treated her with several courses of oral and local vaginal antibiotics with no benefit over the past year and finally increased her prednisolone to 10 mg which she took for a while without any benefit. She was again admitted for surgical correction of her vaginal strictures.
On physical examination there was a well-developed, well-nourished lady who looked somewhat depressed and cried easily during the medical interview. Her vital signs were stable. General physical examination was within normal limits. Her para-clinical work-up were as follows:
Hb: 13.3 g/dl, WBC=4,700/mm3, Normal differential count, platelet: 256,000/mm3
ESR: 21 mm/ first hour,
BUN: 16 mg /dl Creatinine: 0.9 mg/dl FBS: 91 mg/dl
Uric Acid= 4.7 mg/dl Cholesterol = 219 mg/dl TG= 121 mg/dl
ALT= 18 IU/L (nl <40) AST=16 IU/L (Nl < 38) Alk Phos: 246 IU/L (Nl: 64-306)
LDH= 318 IU/L (nl: up to 400) CPK= 77 IU/L (24-170)
Ca=9.8 mg/dl Phosphorus: 3.7 mg/dl
HIV Ab: negative VDRL: Negative
U/A: Yellow, hazy, PH=5, SG=1.026, WBC=10-12/ H.P.F, RBC: 0-1/H.P.F
U/C: Mixed growth
Serum immuno-electrophoresis:
– IgG= 1964 mg/dl (700-1600)
– IgM= 251 mg/dl (40-230)
– IgE= 107 mg/dl (<120)
– IgA=266 mg/dl (70-400)
CMV Ab: negative
She underwent an abdominopelvic ultrasound examination which was within normal limits except for some sludge within the gall bladder. Total colonoscopy and terminal ileal intubation was performed to look for Crohn’s disease which was within normal limits. An upper GI endoscopy was performed which revealed multiple ulcers in a fiery red bed starting from below the UES with highest concentration in the mid- and lower esophagus. There was a three cm sliding hiatal hernia (SHH) as well. The stomach and duodenum were normal and rapid urease test was negative.
A diagnostic procedure was performed 
