2017年 · 第97卷第47期

Cases of lymphoma metastasis to the pituitary gland, both in cases already reported and in patients with advanced clinical tumors, are very rare^[1]。 Malignant tumors that involve the pituitary gland usually show diabetes insipidus or imaging with thickening of the hypothalamus or pituitary infundibulum^[2]。 How to quickly and accurately judge the disease through clinical symptoms and other auxiliary examinations, and give patients correct treatment in time and relieve patients' pain is the focus of research on this kind of disease. The neurosurgery department of Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine diagnosed and treated two patients with lymphoma invading the pituitary gland. The diagnosis and treatment experience of these two cases is reported below.

The 22-year-old male was admitted to the Department of Gastroenterology of Peking Union Medical College Hospital in April 2016 because of "anemia found for 13 years, repeated melena and abdominal pain for 7 years". In 2003, the patient was diagnosed with "iron deficiency anemia" due to "upper respiratory tract infection" in a routine blood test in another hospital showing hemoglobin 60 g/L, no dizziness and palpitations. After oral iron supplementation treatment for about 2 weeks, the drug was discontinued spontaneously, and the blood routine was not re-examined. In June 2009, dull periumbilical pain with melena occurred without trigger, 1 to 2 times a day, lasting for 2 to 3 days, and then relieved spontaneously. In July 2009, the hemoglobin was checked at 40-50 g/L, and the hemoglobin was rechecked at 120 g/L after 2-3 months of oral iron supplementation. In 2014, I began to have recurrent abdominal pain and melena, which lasted for about 2 days and could relieve by itself, with an attack once every 4 weeks. Since 2015, the frequency of attacks has increased to once every 2 weeks, each lasting for 3 to 4 days. During the period, many blood tests showed that microcytic hypochromic anemia could be improved after iron supplementation treatment. Gastroscopy in an external hospital showed: postoperative changes of hiatal hernia; Chronic gastritis; Biliary reflux. Capsule endoscope (Figure 1) shows that the small intestine is scattered with less smooth mucosa, scattered with redness, swelling, erosion and ulcers, accompanied by intestinal lumen stenosis, and the lesion may be located in the jejunum. PET/CT showed multiple enlarged lymph nodes in the mesangial area of peritoneal cavity, but no significant increase in metabolic activity was observed; Esophageal retention. Weight loss of 5 kg 1 year before admission, denied oral vulvar ulcers, perianal lesions, joint swelling and pain, rash, etc. Past history and personal history: The parents were not close relatives, and the mother gave birth naturally at 38 weeks of pregnancy. The patient was diagnosed as "hiatal hernia" at the age of 7 months due to repeated vomiting after eating. He underwent "esophageal hiatal tightening + esophageal fundoplication + diaphragm overlap repair" in the external hospital. He did not vomit again after the operation, but repeated reflux after eating, accompanied by acid reflux, heartburn, and retrosternal pain. He was lying on his back, and occasionally choked and coughed after falling asleep. Since childhood, it is prone to upper respiratory tract infection, and its physical strength and weight are worse than those of peers, and its intelligence level is the same as that of peers.

A 50-year-old male was admitted to the Department of Gastroenterology of Peking Union Medical College Hospital for "repeated diarrhea and abdominal pain for 11 months". The patient developed diarrhea in early December 2015, which was thin watery stool, about 50 ml each time, 4 to 5 times/d, fever, body temperature up to 37.9℃, accompanied by dull pain in the right middle and lower abdomen, no mucus, bloody stool, and night sweats. The blood routine in the local hospital was normal, the erythrocyte sedimentation rate was 48 mm/1 h, and the C-reactive protein was 113 mg/L; Tuberculin test negative. Gastroscopy showed groove-shaped ulcer with peripheral nodular hyperplasia, and multiple shallow ulcers in the stomach body, sinus and angle 34~39 cm away from the incisor; The pathology showed chronic inflammation of the lower esophageal mucosa. Colonoscopy showed multiple ulcers with segmental distribution in the terminal ileum, some ulcers showed longitudinal manifestations, the mucosa between ulcers was normal, and the whole colon was scattered with aphthous ulcers; The pathology showed moderate to severe chronic inflammation of the mucosa, focal erosion, granuloma formation, negative acid-fast staining and negative cytomegalovirus immunohistochemistry. Considering the possibility of infectious enteritis, infusion of levofloxacin, clindamycin and nutritional support were given. The condition improved transiently and worsened again after one month. In March 2016, I went to another hospital. Considering the possibility of "Crohn's disease", I was added with prednisone 20 mg/d for 1 month, then reduced by 5 mg every 3 weeks to 5 mg/d for maintenance, and added mesalazine 0.8 g/d. The patient's diarrhea and fever symptoms improved compared with before, but the diarrhea worsened again after prednisone was reduced to 10 mg/d, accompanied by fatigue. The onset to deny repeated oral vulvar ulcers, arthralgia, pyoderma gangrenosum, erythema nodosum, no anal fistula, perianal abscess. The body mass decreased by about 17.5 kg in half a year. Past history: Hepatitis B virus surface antigen, e antibody, c antibody positive for many years, hepatitis B virus DNA negative, no antiviral treatment was added. He suffered from tuberculosis when he was young, and recovered after regular anti-tuberculosis. Personal history: Hospital pharmacist, denying history of intimate contact with tuberculosis patients. Admission physical examination: wasting, anemic appearance, superficial lymph nodes not reached, clear breathing sounds in both lungs, and no murmur in the heart. The abdomen was soft, without tenderness and rebound pain, and the liver and spleen were not reached under the costs, and the abdominal mass was not palpable.

The 25-year-old male was admitted to the First Affiliated Hospital of Zhengzhou University in March 2017. He had urethral neoplasms for half a year. Two months after urethral splitting and intraurethral mass resection, the neoplasms recurred for two weeks. Six months ago, due to the discovery of multiple cauliflower-like vegetations in the urethral opening, the surface was rough and the urine line became thinner, and I went to many local hospitals successively. X-ray contrast showed irregular filling defect of the anterior urethra (Figure 1)； Urethroscopy showed that villous neoplasms covered the urethral mucosa from the outer opening of the urethra to the root of the penis; Pathological examination of intraurethral neoplasms: squamous epithelial papilloma with cavity-like cells in the epithelium (Figure 2)； HPV-DNA type 11, 58 positive; Color Doppler ultrasound showed no obvious abnormalities in both kidneys and ureters, poor bladder filling, smooth inner wall, and no obvious abnormal echoes. Diagnosis: (1) multiple urethral tumors; (2) Viral warts. For further treatment, I went to a hospital in other places 2 months ago. After urethral splitting and intraurethral mass resection, the skin lesions resolved. Two weeks ago, extensive cauliflower-like growth was found in the urethral mucosa from the outer urethral opening to the root of the penis, so I went to the Department of Dermatology, the First Affiliated Hospital of Zhengzhou University. In the past, he was healthy and denied the history of metallurgical tours. After admission, the routine of hematuria and feces was normal; Treponema pallidum antibody and human immunodeficiency virus antibody were both negative; There were no obvious abnormalities in immunoglobulin and complement; Lymphocyte subsets: absolute T lymphocyte count 3 277 (770-2 860) /μ l, absolute helper T lymphocyte count 2 006 (414-1 440) /μ l, suppressor T lymphocyte count 1 010 (238-1 250) /μ l, helper/suppressor lymphocyte count 1.99 (0.68-2.47). Physical examination: No obvious abnormalities in heart and lung. Dermatological examination: After urethral splitting, the anterior urethra is open, and multiple cauliflower-like vegetations can be seen in the urethral mucosa from the outer opening of the urethra to the root of the penis, the size of millet to soybean, partially fused, pale, reddish to gray-red, and the surface is rough (Figure 3)。 According to the medical history, clinical manifestations, imaging examination, pathological examination and HPV-DNA test results, the diagnosis was: extensive condyloma acuminatum in the anterior urethra. 5-aminoketovaleric acid-photodynamic (ALA-PDT) therapy, supplemented with recombinant human interferon a-2b gel for topical use, thymosin tablets 10 mg and lentinan polysaccharide tablets 20 mg, orally administered twice/d; The concentration of 5-aminoketovaleric acid in photodynamic therapy was 5%, the application time was about 4~5 h, and the irradiation time of 100 mW He-Ne laser was 30 min. After one treatment, the wart resolved by about 90% (Figure 4), the skin lesions resolved after 3 treatments, and the mucosa was smooth and pink, but HPA-DNA re-examination was not performed, and the patient was lost to follow-up after the 4th treatment.

Liver failure is a common severe liver disease syndrome in clinic, and the mortality rate is extremely high. Artificial liver technique is one of the important methods in the treatment of liver failure in recent years. It can temporarily replace part of the failed liver function, create conditions for hepatocyte regeneration and liver function recovery, and effectively improve the short-term survival rate of patients with liver failure^[1]。 During the clinical application of artificial liver treatment, adverse reactions are more common in allergy, hypotension, digestive tract symptoms, etc. Heparin-induced thrombocytopenia (HIT) is the thrombocytopenia and thrombosis caused by the application of heparin, and has a high disability and mortality rate^[2,3]。 At present, many methods of artificial liver in clinic involve cardiopulmonary bypass and the use of anticoagulants, among which heparin is the most widely used anticoagulant. Thrombocytopenia caused by heparin in the treatment of artificial liver is rare, which will have an extremely serious impact on the patient's recovery, and clinicians need to actively deal with it. A case of heparin-induced thrombocytopenia in a patient with liver failure admitted to our department during artificial liver therapy is reported as follows.

A 62-year-old female was admitted to the Department of Gastroenterology, the First Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine because of "repeated abdominal distension for more than 8 years". The patient had obvious abdominal distension after eating, and no symptoms such as abdominal pain, nausea and vomiting. The local hospital has repeated gastroscopy, colonoscopy, abdominal CT and other examinations. Weight loss of about 15 kg in 8 years. After admission, there were no differences in biochemistry, tumor, coagulation, thyroid function and blood routine. The imaging examination showed abdominal B-ultrasound and abdominal CT. Gastroscopy showed an irregular shallow depression of about 0.8 cm ×1.5 cm in the body of the stomach, with uneven bottom and unclear boundary (Figure 1)； Magnification endoscopy combined with narrowband imaging (ME-NBI) technique showed that the local microstructure disappeared, some crypts were widened, and the microvessels were thickened and uniform in thickness. The thickened microvessels were in the glandular duct (FIG. 2A), dendritic vessels are visible locally, (Figure 2B)。 Endoscopic ultrasound showed that the lesions were located in the mucosal layer and submucosal layer. Pigment staining endoscopy showed that the extent of the lesions was unclear. Multiple gastroscopic pathologies showed chronic inflammation of the mucosa, and lymphoma could not be excluded. Considering that the previous biopsy site was superficial, in order to further clarify the condition and communicate with the patient's family members, the patient and his family members gave up another deep biopsy, and after excluding the contraindications of surgery, diagnostic endoscopic submucosal dissection (ESD) was performed. The size of the ESD macro-examination specimen was 4 cm ×3.8 cm ×0.3 cm, with a superficial depression in the center, about 1.5 cm ×0.8 cm, and a white scar was seen on the surface of the specimen (Figure 3)。 Microscopic examination showed diffuse infiltration of small to medium-sized lymphocytes in the lamina propria with lymphoid follicular formation, and lymphoepithelial lesions (Figure 4), negative margin, consistent with gastric mucosa-associated lymphoid tissue (MALT) lymphoma, HP (+). Immunohistochemical results: P53 (<5% +), Ki-67 (10%), CD20 (+), CD79a (diffuse +), Bcl-2 (+), MUM1 (+), CD21 (+), CK broad spectrum [glandular epithelium (+)], CD3-, CD4-, CD5 [small amount (+)], CyclinD1 (-), Bcl-6 (-) (Figure 5)。 The final diagnosis was gastric MALT lymphoma stage I, which was treated with conventional anti-Helicobacter pylori for 2 weeks. After HP turned negative, no abnormalities were found in gastroscopy for 3 years.