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Scientific letter
Granulomatous gastritis induced by onychophagia: First case report
Gastritis granulomatosa inducida por onicofagia: primer relato de caso
Rui Moraisa,
Corresponding author
rui_morais20@hotmail.com

Corresponding author.
, Amadeu C.R. Nunesa, Elisabete Riosb, Susana Rodriguesa, Guilherme Macedoa
a Gastroenterology Department, Centro Hospitalar de São João, Porto, Portugal
b Pathology Department, Centro Hospitalar de São João, Porto, Portugal
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Her past medical history was irrelevant and her usual medication was omeprazole 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day due to occasional symptoms of epigastric pain with years of evolution&#46; An upper endoscopy did not reveal lesions&#44; but multiple biopsies of the gastric mucosa were taken&#46; Gastric biopsies revealed chronic inflammatory process with formation of lymphoid follicles and evidence of <span class="elsevierStyleItalic">Helicobacter pylori</span> infection&#46; Additionally&#44; multiple well-defined and non-necrotizing epithelioid granulomas with multinucleated giant cells were found &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#46; In one of the granulomas it was identified a birefringent material compatible with a foreign body &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C and D&#41;&#46; No acid-fast bacilli &#40;Ziehl&#8211;Neelsen stain&#41; or fungal microorganisms &#40;PAS and PAS-D stains&#41; were observed&#46; No additional microbiological studies were performed&#46; A diagnosis of GG&#44; related to a probable foreign material was made&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After a careful clinical history&#44; the patient reported the habit of biting and ingesting nails since childhood&#46; She denied history of onychomycosis&#44; use of nail polish or other nail beauty item lately&#46; The patient had recently begun her work as a teacher and denied contact with chemicals products in her job or at home&#46; Nevertheless&#44; she underwent a colonoscopy and videocapsule endoscopy that excluded Crohn&#39;s disease&#46; She was referred to the Infectious Diseases outpatient clinic and tuberculosis was excluded with chest X-ray&#44; Mantoux test and QUANTIFERON<span class="elsevierStyleSup">&#174;</span>-TB Gold test&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After six months of avoiding nail ingestion&#44; the patient became asymptomatic&#46; She underwent a subsequent upper endoscopy&#46; Multiple gastric biopsies were undertaken and disclosed moderate chronic <span class="elsevierStyleItalic">H&#46; pylori</span> gastritis but no granulomas or foreign material were seen&#44; confirming resolution of GG &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8211;C&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Granulomatous gastritis is an uncommon pathological finding&#44; with a reported incidence of 0&#46;08&#8211;0&#46;35&#37; in the gastric biopsy samples&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a> The most common cause of GG in the western countries is Crohn&#39;s disease accounting for approximately half of the cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;6</span></a> Other more rare causes include gastric tuberculosis&#44; sarcoidosis&#44; parasitic infections&#44; foreign body reactions&#44; Whipple&#39;s disease and adenocarcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Miyamoto et al&#46; also described a possible association with <span class="elsevierStyleItalic">H&#46; pylori</span> infection with two reported cases of granulomatous gastritis resolution after successful eradication therapy for <span class="elsevierStyleItalic">H&#46; pylori</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> Nevertheless there is still controversy in relation to the role of <span class="elsevierStyleItalic">H&#46; pylori</span> as a causative factor in GG&#44; with larger studies unable to conclusively associate <span class="elsevierStyleItalic">H&#46; pylori</span> infection with granuloma formation&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;9</span></a> In our case&#44; since the patient presented with disabling symptoms and weight loss our priority was to exclude Crohn&#39;s disease and tuberculosis&#46; The presence of foreign material in the biopsies&#44; granulomatous gastritis and habit of nail ingestion suggested this association&#46; Since the role of <span class="elsevierStyleItalic">H&#46; pylori</span> in the development of GG is still controversial&#44; we decided not to eradicate <span class="elsevierStyleItalic">H&#46; pylori</span> and evaluate the clinical and histological response to suspension of nail ingestion&#46; In our patient&#44; it is likely that the symptoms of epigastric pain with years of evolution may be related to the habit of nails ingestion&#46; The continuous exposure of the gastric mucosa to a foreign body material probably lead to the development of a granulomatous process with subsequent symptomatic aggravation&#46; Given that the patient became asymptomatic and there was an evident histological improvement&#44; we can conclude that nails ingestion &#40;onychophagia&#41; was the cause of GG in this case&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">No conflicts of interest to declare&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Gastric mucosa with epithelioid granulomas &#40;A &#8211; H&#38;E stain&#44; &#215;100&#59; B &#8211; H&#38;E stain&#44; &#215;200&#41;&#46; In the PAS staining a foreign body&#44; highlighted by the circle&#44; was detected in one of the granulomas &#40;C &#8211; PAS stain&#44; &#215;200&#59; D &#8211; PAS stain&#44; &#215;400&#41;&#46;</p>"
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