Vol 44 # 4 December 2012 - Kma.org.kw

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337 Celiac Disease as Uncommon Cause of Death in Type 1 Diabetes Mellitus: A Case Study December 2012 highly suspected. Compliance with GFD is likely to be protective against development of non-Hodgkin lymphoma and dermatitis herpitiformis in CD. It can improve nutritional status, body mass index, increase insulin requirement in type 1 diabetes, but no convincing change in diabetes control [10] . CD patients have overall, two-fold increased mortality risk compared with the general population. CD elevates the mortality risks of a wide array of diseases in CD patients, including non-Hodgkin lymphoma (SMR 11.4), small intestinal cancer (SMR m 17.3), autoimmune diseases as rheumatoid arthritis (SMR 7.3) and diffuse disease of connective tissue (SMR 17.0), allergic disorders such as bronchial asthma (SMR 2.8), inflammatory bowel disease including ulcerative colitis and Crohn’s disease (SMR 70.9), diabetes mellitus (SMR 3.0), disorders of immune-deficiency (SMR 20.9), tuberculosis (SMR 5.9), pneumonia (SMR 2.9) and nephritis (SMR 5.4) [11] . CONCLUSION It is important to have a high index of suspicion for CD in adult patients with type 1 diabetes mellitus, in view of the common association between these two diseases and the elevated mortality risks for a wide array of diseases in CD patients. REFERENCES 1. Green PH, Jabri B. Coeliac disease. Lancet 2003; 362:383- 391. 2. Armin A, Peter HR. Narrative review: Celiac Disease: Understanding a complex autoimmune disorder. Ann Intern Med 2005; 142: 289-298. 3. Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med 2003; 163:286-292 4. Tommasini A, Not T, Kiren V, et al. Mass screening for coeliac disease using antihuman transglutaminase antibody assay. Arch Dis Child 2004; 89:512-515 5. Holmes GK. Coeliac disease and type 1 diabetes mellitus - the case for screening. Diabet Med 2001; 18:169-177. 6. Noel P, Françoise B, Charlotte B, et al. The temporal relationship between the onset of type 1 diabetes and celiac disease: A study based on immunoglobulin A antitransglutaminase screening. Pediatrics 2004; 113: e418-e422. 7. Frank W, Aonghus O, Fidelma D. Gluten and glucose management in type 1 diabetes. B J Diab Vasc Dis 2008; 8:67-71. 8. Maria T, Mirella F, Maurizio Q, Nicoletta I, Paolo B, Dario C. Prevalence of hypertransaminasemia in adult celiac patients and effect of gluten-free diet. Hepatology 1995; 22:833-836. 9. Alberto Rub, Joseph A. The liver in celiac disease. Hepatology 2007; 46:1650-1658. 10. Rostom A, Murray JA, Kagnoff MF. American Gastroenterological Association (AGA) Institute technical review on the diagnosis and management of celiac disease. Gastroenterology 2006; 131:1981-2002. 11. Peters U, Askling J, Gridley G, Ekbom A, Linet M. Causes of death in patients with celiac disease in a population-based Swedish cohort. Arch Intern Med 2003; 163:1566-1572.
December 2012 KUWAIT MEDICAL JOURNAL 338 Case Report Squamous Cell Carcinoma of the Penis: Magnetic Resonance Imaging Findings Ibrahim Hamed, Hasan Almutairi, Muneera Al-Adwani Department of Clinical Radiology, Al-Jahra Hospital, Kuwait Kuwait Medical Journal 2012; 44 (4): 338 - 340 ABSTRACT Most primary penile malignancies are squamous cell carcinoma (SCC) and occur most often during the 6 th and 7 th decades of life. Uncircumcised men are more often affected, probably because of the chronic irritative effect of smegma. An association between human papilloma viruses 16 and 18 and SCC of the penis has also been reported. We describe a case of a 43-year-old uncircumcised Asian male patient who presented with an ulcerating penile mass. MRI images were helpful in making a preoperative diagnosis of penile cancer. MR imaging can play an important role in the evaluation of a penile mass. KEY WORDS: penile mass, penile SCC, MRI of penis INTRODUCTION Squamous cell carcinoma (SCC) of the penis usually begins on the glans as a focal epithelial thickening with or without ulceration [1] . The lesions are generally not painful, and affected patients often delay seeking medical attention [2] . After penectomy with 2 cm margins, patients with tumors that have not invaded the corpora cavernosa have a greater than 95% 3-year survival rate [3] . Survival decreases markedly with cavernosal invasion or with spread to regional lymph nodes [4] . Although not often performed in the acute setting, MR imaging can play an important role in the evaluation of penile mass [5] . Ultrasound (US) can help detect solid penile mass in the majority of patients [6] . CASE HISTORY An Indian uncircumcised male patient aged 43 years presented with a painless penile mass of sixmonth duration. The clinical examination revealed a solid mass lesion underneath the foreskin and the patient was referred to our department for an MRI. MRI revealed a solid isointense to low signal intensity mass lesion both on T1-wieghted (Fig. 1) and T2-wieghted (Fig. 2) images, mainly located at the left lateral aspect of the glans of the penis extending to its dorsal aspect with a definite invasion of the hypointense adjacent tunica albuginea (Fig. 3). However, the urethra was not compromised (Fig. 3). After Gd-chelate agent injection, homogenous enhancement pattern was elicited with multiple signal void foci that were confirmed to be hypervascular on color Doppler study (Fig. 3 and Fig. 4). The clinical examination revealed a solid mass lesion underneath the foreskin (Fig. 5) with concealed external meatus and with discharge from cutaneous fistula from the foreskin. Diagnosis and Treatment: Circumcision with excisional biopsy was done and histopathological examination confirmed penile SCC. So the patient underwent partial penectomy with 2 cm safety margin. The patient was planned for bilateral ilio-inguinal lymph node dissection. DISCUSSION Carcinoma of the urethra and penis is extremely rare, accounting for less than 1% of genitourinary cancers in males [7] . Histological examination reveals SCC in more than 95% of cases of penile carcinoma [8] . At MR imaging, SCC is usually hypointense relative to the corpora on both T1- (Fig. 1) and T2- (Fig. 2) weighted images. At contrast-enhanced imaging, these lesions do increase in signal intensity but less so than the normal corporal bodies. Although neither MR nor other imaging is generally needed for diagnosis (the tumor is usually visible at physical examination), MR imaging may be performed for staging purposes. In the commonly used Jackson staging system, stage I lesions are confined to the glans or prepuce, stage II lesions Address correspondence to: Ibrahim Mohamed Ali Hamed, MD, Department of Clinical Radiology, Al-Jahra Hospital (MoH),Jahra Central, PO Box 1807, Jahra 01020, Kuwait. Fax: 24577198, 97341802 (M), E-mail: imah_77@hotmail.com, mun.adw@windowslive.com
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