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Base of Tongue Varices Associated with Portal Hypertension

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Base of Tongue Varices Associated with Portal Hypertension 576 Postgrad Med J 2000;76:576–577 Postgrad Med J: first published as 10.1136/pmj.76.899.577 on 1 September 2000. Downloaded from CASE REPORTS Base of tongue varices associated with portal hypertension P Jassar, M Jaramillo, D A Nunez Abstract underwent ablation of the varicosities using a A symptomatic case of tongue base 15 watt continuous carbon dioxide laser under varices in a patient with portal hyper- general anaesthesia (see fig 2). She had an tension secondary to liver cirrhosis is uneventful recovery and has remained symp- presented. There are no previously docu- tom free. mented cases in the world literature. Oesophageal varices may not be the only Anatomy source of expectorated blood in a patient The dorsal lingual veins drain the tongue base with portal hypertension. through two or more tributaries. These course (Postgrad Med J 2000;76:576–577) inferiorly, join together and form the lingual vein, which accompanies the lingual artery. Keywords: portal hypertension; lingual; tongue; vari- These vessels pass between genioglossus and cose vein hyoglossus and the vein empties into the inter- nal jugular vein just above the level of the Case report 1 An 82 year old women with known portal greater cornu of the hyoid bone. hypertension secondary to cirrhosis of the liver was referred to the otolaryngology outpatient PORTOSYSTEMIC ANASTOMOSIS department with a two month history of daily Because the portal system has no valves, portal haemoptysis and bloodstained pharyngeal se- hypertension results in shunting of blood cretions; this occurred mostly on early morning through anastomotic communications with the coughing. There was no history of weight loss, systemic venous system. Recognised connec- dysphagia, dysphonia, or throat pain. She had tions are2: already been investigated for a pulmonary (1) Lower oesophageal veins—the branches cause of the haemoptysis and none was found. of the left gastric vein anastomose profusely In keeping with her history, liver function tests with the azygous and hemiazygous veins. and the prothrombin time were abnormal. She Increased shunting results in oesophageal also had a history of well controlled essential varices within the mucosa of the lower third of hypertension. Chest radiography showed the oesophagus. http://pmj.bmj.com/ cardiomegaly, but the jugular venous pressure (2) Periumbilical veins—veins contained in was not raised and there was no other clinical the falciform ligament anastomose with supe- manifestation of heart failure. rior and inferior epigastric veins of the anterior Indirect laryngoscopy revealed varicose ves- abdominal wall. Excessive dilatation of these sels in the tongue base, mainly on the left side veins are evident as caput medusa. (see fig 1). These appeared friable and one area (3) Haemorrhoids—the superior rectal vein revealed a propensity to bleed on examination. anastomoses with the middle rectal vein which The rest of the ear, nose, and throat examina- drains into the internal iliac vein. In addition on October 1, 2021 by guest. Protected copyright. tion was normal. the middle rectal veins anastomose with the After perioperative cover with fresh frozen inferior rectal veins which drain into the inter- plasma, vitamin K, and tranexamic acid she nal pudendal vein. Increased shunting results in internal and external haemorrhoids. Department of Otolaryngology, Aberdeen Royal Infirmary, UK P Jassar M Jaramillo D A Nunez Correspondence to: Mr D A Nunez, Department of Otolaryngology, Ward 45, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK (email: [email protected]) Submitted 28 October 1999 Accepted 10 February 2000 Figure 1 Tongue base varices. Figure 2 Tongue base varices after laser ablation. www.postgradmedj.com Cefuroxime induced lymphomatoid hypersensitivity reaction 577 Postgrad Med J: first published as 10.1136/pmj.76.899.577 on 1 September 2000. Downloaded from (4) Veins of Retzius—the veins of a second- nations for this association. Firstly that the ary retroperitoneal structure may anastomose varices represent a spontaneous entity unre- with the veins of the dorsal body wall, forming lated to systemic disease. Secondly, they are a veins of Retzius. manifestation of cardiopulmonary disease, an Thus, there is no recognised anastomosis association endorsed by the known anatomic between lingual venous drainage and the portal connection, but improbable given that there circulation. was no other clinical evidence of heart failure such as a raised jugular venous pressure. Lastly, Discussion that there is an, as yet, unrecognised anasto- A varicosity is a condition indicating an motic connection between lingual venous enlarged and tortuous vein. Previously de- drainage and the portal circulation. scribed lingual varices referred to sublingual Tongue base varices should be considered in varices on the ventral surface of the tongue or floor of mouth. These were ascribed to the use cases of blood expectoration and portal hyper- of dentures, and vitamin C deficiency in an tension. elderly population.3 Burket associated the occurrence of lingual 4 1 Gray H. Gray’s anatomy. 15th Ed. New York:Bounty Books, varices with cardiorespiratory disease, how- 1978: 598. ever this assumption was shown to be unsub- 2 April EW. Anatomy. 2nd Ed. National Medical Series. stantiated in a double blind study by Baltimore: Williams and Wilkins, 1990: 229–30. 5 3 Colby RA, Kerr DA, Robinson HBG. Colour atlas of oral Kleinman. pathology. 2nd Ed. Philadelphia: JB Lippincott, 1961: 125. This represents the first reported case of 4 Burket LW. Oral medicine. 4th Ed. Philadelphia: JB Lippin- cott, 1961: 146. dorsal tongue base varices in a patient with 5 Kleinman HZ. Lingual varicosities. Oral Surgery, Oral Medi- portal hypertension. We propose three expla- cine, Oral Pathology 1967;23:546–8. Cefuroxime induced lymphomatoid hypersensitivity reaction S A M Saeed, M Bazza, M Zaman, K S Ryatt Abstract a short history of fever, acute abdominal pain, An 84 year old women developed ery- and diarrhoea. On examination she was found thematous blotchy erythema and purpu- to be toxic, febrile, dehydrated, with a tachycar- http://pmj.bmj.com/ ric rashes over the lower limbs three days dia of 110/min and blood pressure 80/40 mm after being started on intravenous cefuro- Hg. The left iliac fossa was tender. Haemo- xime for acute diverticulitis. A skin biopsy globin, full biochemistry profile, specimen showed a mixed infiltrate of including serum amylase, chest radiography, lymphoid cells and eosinophils; many of plain abdominal radiography, and an abdomi- the lymphocytes were large, pleomorphic, nal ultrasound scan were normal. Her white 9 and showed a raised mitotic rate.Immuno- cell count was raised at 20.4 × 10 /l with 9 histochemistry showed the infiltrate to be marked neutrophilia at 14.2 × 10 /l. on October 1, 2021 by guest. Protected copyright. T cell rich, with all the large cells being A provisional clinical diagnosis of acute diver- CD30 positive. Typical mycosis fungoides ticulitis with septic shock was made and she was cells, marked epidermotropism, and Pau- started on intravenous (IV) fluids, IV metroni- trier’s abscesses were not seen. The rash dazole 500 mg eight hourly, and IV cefuroxime Manor Hospital, disappeared 10 days after cessation of 750 mg three times a day in a sequential Walsall, UK: cefuroxime and the patient remained manner. Three days later and after five doses of Department of Elderly asymptomatic 15 months later. This ap- IV cefuroxime, purpuric and erythematous Care parent cutaneous T cell lymphoma-like macular rashes developed over the lower limbs. S A M Saeed Cefuroxime was considered to be responsible reaction is best described as lymphoma- M Zaman and was discontinued; metronidazole was con- toid vascular reaction. The drug induced tinued for another week. The rashes were treated Department of immune response with an atypical cutane- with flucinolone acetonide 0.00625% cream. Dermatology ous lymphoid infiltrate mimics a cutane- Further investigations at this stage showed nor- M Bazza ous pseudolymphoma. KSRyatt mal immunoglobulins, antinuclear factor, an- (Postgrad Med J 2000;76:577–579) tineutrophilic cytoplasmic antibodies, and au- Correspondence to: Dr M Bazza, Department of Keywords: cefuroxime; atypical cutaneous lymphoma- toantibody profile. A haematoxylin and eosin Dermatology, Walsall Manor toid infiltrate; cutaneous T cell lymphoma stained section of representative skin biopsy Hospital, Walsall, West showed a mixed dermal infiltrate of lymphoid Midlands WS2 9 PS, UK Case report cells and eosinophils, marked red blood cell Submitted 21 April 1999 An 84 year old women, with established diver- extravasation indicative of ongoing small vessel Accepted 7 December 1999 ticula disease, presented as an emergency with damage, minimal focal vacuolar interface www.postgradmedj.com 578 Saeed, Bazza, Zaman, et al Postgrad Med J: first published as 10.1136/pmj.76.899.577 on 1 September 2000. Downloaded from Pyrexia, diarrhoea, tachycardia, and hypo- tension improved rapidly with supportive measures and the rashes began to fade quickly and cleared within seven days. She was completely asymptomatic and clear of all rashes when reviewed more than 15 months after the initial episode. Discussion Cephalosporins are widely used for the treat- ment of septicaemia, pneumonia, meningitis, biliary and urinary tract infection, and perito- nitis. Both the old and new third generations of cephalosporins are generally well tolerated at standard recommended dosage.1 The sequen- tial cefuroxime
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