A 75-year-old male patient, a known case of Type II diabetes mellitus and hypertension for the last 2 years, presented with the complaints of intolerance to oral feeds for 2 months, initially intolerant to solids and gradually developing intolerance to liquid diet for the past 2 weeks associated with altered blood in vomitus and drooling of saliva. The patient complained of cough with expectoration for the past 2 months. The patient also complained of having upper abdominal pain for the past 2 months, which was burning, intermittent, and nonradiating, and there was no history of diarrhea. He also had a history of melena for the past 2 months. On examination, the patient was conscious, oriented, and afebrile. Vitals were within normal limits. The patient was poorly built. His general physical examination revealed pallor. Systemic examination revealed coarse crepitus in the bilateral lung fields. Per abdomen, there was mild diffuse tenderness with sluggish bowel sounds on auscultation. On direct rectal examination, presence of melena was noted. Chest radiograph revealed bilateral mild pleural effusion with irregular opacity in the right upper zone [Figure 1a]. Nebulization with salbutamol for 6 h and parenteral ceftriaxone 1 g twice daily was started. Contrast-enhanced computed tomography (CECT) abdomen revealed a large polypoidal lesion in the anterior wall of the antero-pyloric region, causing complete luminal obstruction [Figure 1b]. It also revealed multiple, enlarged perigastric, periportal, celiac, pre-aortic, para-aortic, and aortocaval nodes. Omental nodes were present with mild ascites [Figure 1c]. CECT thorax showed extensive bilateral centrilobular emphysematous changes. Irregular opacities with adjacent bands were seen in the right upper lobe, suggestive of fibrotic changes. Bilateral moderate pleural effusion was seen [Figure 1d]. Routine biochemical and hematological investigations revealed blood glucose of 240 mg/dL with a normal HbA1c of 4.5%, low hemoglobin (6.7 g%), and normal renal and liver function test. Serum samples were negative for HIV, hepatitis B virus, and hepatitis C virus. Histopathology of the gastric biopsy specimen showed moderately differentiated adenocarcinoma. Sputum sample of the patient was sent for culture of Mycobacterium tuberculosis. The sample was decontaminated by N-acetyl-l-cysteine-sodium hydroxide method and stained with auramine phenol stain. In auramine phenol stain, fluorescent circular structures measuring 4-7 mum were observed [Figure 2a]. The bacterial culture was negative and there was no growth of M. tuberculosis in the culture. Modified Ziehl-Neelsen staining showed circular acid-fast structures measuring 4-7 mum [Figure 2b], which were identified as Cryptosporidium species based on morphological characteristics. The patient was started on tablet nitazoxanide 500 mg twice daily for 3 days. Stool examination was negative for oocysts of Cryptosporidium spp.
The patient was diagnosed as a case of metastatic carcinoma of the stomach. As the patient presented with hematemesis, he was managed conservatively with tranexamic acid and pantoprazole. Hemostatic radiotherapy was given following which bleeding from the tumor was controlled. There were no symptoms of melena or hematemesis at discharge. Feeding jejunostomy could not be carried out in view of the patient's poor condition. The patient was taking restricted oral fluids. The patient was discharged with advice for follow-up. However, on telephonic follow-up, it was found that the patient expired few days after the discharge.
Chest X-ray and contrast-enhanced computed tomography of the abdomen and thorax. (d) (solid yellow arrow) Emphysematous changes in the lung fields on contrast-enhanced computed tomography thorax and (empty arrow) pleural effusion.