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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 4  |  Page : 645-646
Pseudomelanosis Duodeni in a Child with Chronic Renal Failure


1 Department of Pathology, Children Medical Center Hospital, Tehran University of Medical Sciences, Keshavarz Boulevard, Tehran, Iran
2 Department of Pediatric Gastroenterology, Children Medical Center Hospital, Tehran University of Medical Sciences, Keshavarz Boulevard, Tehran, Iran
3 Department of Pediatric Nephrology, Children Medical Center Hospital, Tehran University of Medical Sciences, Keshavarz Boulevard, Tehran, Iran

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How to cite this article:
Monajemzadeh M, Tayari N, Najafi M, Madani A, Mahjoub F, Esfahani ST, Ataei N, Ashtiani MT, Mohseni P, Shams S. Pseudomelanosis Duodeni in a Child with Chronic Renal Failure. Saudi J Kidney Dis Transpl 2008;19:645-6

How to cite this URL:
Monajemzadeh M, Tayari N, Najafi M, Madani A, Mahjoub F, Esfahani ST, Ataei N, Ashtiani MT, Mohseni P, Shams S. Pseudomelanosis Duodeni in a Child with Chronic Renal Failure. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Nov 24];19:645-6. Available from: https://www.sjkdt.org/text.asp?2008/19/4/645/41330
To the Editor,

The presence of a spotty brownish or blackish pigmentation in the duodenal mu­cosa at endoscopy, termed duodenal mela­nosis or pseudomelanosis is a rare benign condition. Histochemically, the pigment ap­peared to contain either iron, melanin like substances or both. Pseudomelanosis duo­deni is very rarely seen in children. [1]

In 1976, Bisordi and Kleinman reported an unusual patient with patchy, 'peppered', pigmentation in the second part of the duodenum and since that time, few similar cases have been reported in the medical literature but most of them are in adult patients. [1],[2]

Its pathogenesis and significance, however, remain obscure. [1] With electron microscopy and electron-probe energy dispersive X-ray analysis, the pigment has been shown to consist largely of iron sulphide in angular crystalline plates. This is in contrast with melanosis coli where the pigment is lipo­fuscin. [3]

We present herein the endoscopic, micros­copic, and histochemical studies of an eight year-old girl with this condition.

The child was referred because of abdo­minal discomfort and convulsion. She was a known case of polycystic kidney disease and the nephrotic syndrome diagnosed at eight months of age, who developed end­stage renal disease when she was two­years old, and underwent kidney transplant three years later (at the age of 5 years). The transplanted kidney was rejected one month after surgery; she was placed on maintenance hemodialysis with anti-hypertensive drugs including hydralazine, clonidine, amilodipine and oral iron supplements as well as anti convulsant drugs (phenytoin).

Gasteroesophageal endoscopic examination show tiny superficial erosions proximal to the Z line with hiatal hernia, normal gastric mucosa and profuse black spots in the se­cond part of duodenum. Biopsy was taken from the duodenum. Microscopic examina­tion showed some cells filled with black- brown coarse granules scattered in the lamina propria [Figure 1].

The pigment was positive by both the Masson-Fontana method and the Perls' stain. This patient had been treated with hydra­lazine, a drug that contains a sulphur group [4] which together with possible intra-mucosal hemorrhagic events due to stress, medica­tion, hemodialysis and/or renal failure itself compounded by oral iron intake could have resulted in accumulation of iron and sul­phur in the lamina propria.

The question is why every patient with chronic renal failure and use of these drugs does not develop these lesions. It seems that the quantity of iron deposited presu­mably determined whether or not the pig­ment was macroscopically visible. The stai­ning characteristics of the pigment on the other hand might be related to the amount of sulphur present in the pigment. [1],[5]

Our results indicate that hypertension; gastrointestinal hemorrhage, renal insuffi­ciency and anemia are factors involved in pigmentation of the duodenum and it can occur in children like adult patients espe­cially if there is longstanding disease like our case (about 8 years).

Awareness of this condition among gastro­enterologists, pathologists, and other clini­cians can aid in better identification of such patients and also aid in evaluation of other possible variables in its pathogenesis.

 
   References Top

1.Kang JY, Wu AY, Chia JL, Wee A, Sutherland IH, Hori R. Clinical and ultra­structural studies in duodenal pseudo­melanosis. Gut 1987;28(12):1673-81.  Back to cited text no. 1    
2.Giusto D, Jakate S. Pseudomelanosis duodeni: associated with multiple clinical conditions and unpredictable iron staina­bility-A case series. Endoscopy 2008;40 (2):165-7.  Back to cited text no. 2    
3.Nascimbeni R, Donato F, Ghirardi M, Mariani P, Villanacci V, Salerni B. Consti­pation, anthranoid laxatives, melanosis coli, and colon cancer: a risk assessment using aberrant crypt foci. Cancer Epidemiol Biomarkers Prev 2002;11(8):753-7.  Back to cited text no. 3    
4.Cantu JA, Adler DG. Pseudomelanosis duodeni. Endoscopy 2005;37(8):789.  Back to cited text no. 4    
5.Shoden A, Sturgeon P. Iron storage, IV: cellular distribution of excess liver iron. Am J Pathol 1962;40:671-83.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Maryam Monajemzadeh
Department of Pathology, Children Medical Center Hospital, Tehran University of Medical Sciences, Keshavarz Boulevard, Tehran
Iran
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PMID: 18580029

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