[Phlegmonous gastritis in a 44-year-old woman on immunosuppressive therapy].
METHODS
A 44-year-old woman was on long-term immunosuppressive therapy with leflunomide and adalimumab for rheumatoid arthritis. She was admitted to the emergency room with diffuse abdominal pain of sudden onset. On physical examination she had rebound tenderness in all four abdominal quadrants.


METHODS
The white blood cell count was 3300/l, C-reactive protein 25 mg/dl and serum lactate 10 mmol/l. Abdominal computed tomography revealed a diffusely thickened gastric wall and ascites. At explorative laparotomy 1000 ml of a cloudy peritoneal fluid were aspirated and found to be negative for bacteria. But a culture of a mesenterial smear grew streptococci group A. Intra-operative endoscopy showed extensive hemorrhagic gastritis. Because there was no perforation or transmural necrosis gastric resection was not performed.


METHODS
Diffuse thickening of the gastric wall, extended mucosal necrosis and the peritoneal finding of streptococci in an immunocompromised patient suggested the diagnosis of phlegmonous gastritis. On treatment with antibiotics and proton pump inhibitor the patient made a slow recovery over the following eight weeks. Nine months after the event an asymptomatic antral stricture was noticed at follow-up gastroscopy.


CONCLUSIONS
Phlegmonous gastritis is a rare but life-threatening complication in immunosuppressed patients.
Scheppach
W
W
Medizinische Klinik mit Schwerpunkt Gastroenterologie/Rheumatologie, Juliusspital Würzburg, Würzburg, Germany. w.scheppach@juliusspital.de
Illert
B
B
Zettl
A
A
Kneitz
C
C
Scheurlen
M
M
D015746:Abdominal Pain / Q000209:etiology; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy; D001201:Ascites / Q000209:etiology / Q000382:microbiology; D005260:Female; D005756:Gastritis / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology / Q000601:surgery; D005773:Gastroscopy; D006801:Humans; D016867:Immunocompromised Host; D007166:Immunosuppressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D010535:Laparoscopy / Q000379:methods; D054328:Proton Pump Inhibitors; D013290:Streptococcal Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology / Q000601:surgery; D013297:Streptococcus pyogenes / Q000302:isolation & purification*; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; D007166:Immunosuppressive Agents; D054328:Proton Pump Inhibitors