Iron pill-induced gastroduodenopathy

A 76-year-old man with previous history of kidney transplantation in 2003 (due to chronic kidney injury of unknown etiology), arterial hypertension and a thoracoabdominal aortic aneurysm was admitted to our center for a thoracic endovascular repair. His usual medication was tacrolimus, mycophenolate mofetil, prednisolone, captopril and carvedilol. After surgery the patient was referred for an abdominal computed tomography (CT) due to epigastric pain and vomiting with associated hemoglobin drop to 8 g/dl (from a previous value of 14 g/dl). CT scan revealed a massive retroperitoneal hematoma (12 × 6.5 cm). Blood transfusions were undertaken and due to iron deficiency anemia, oral ferrous sulfate was initiated. One week later, the patient was referred for an upper endoscopy due to dysphagia. Upper endoscopy did not show esophageal lesions; however multiple erosions in the gastric body were detected (Fig. 1) with biopsies revealing extracellular crystalline iron deposition the superficial lamina propria beneath eroded epithelium and in the lumen of the gastric glands, with some focal intracellular granular iron deposition in glandular cells, confirmed by Perls’ iron (Prussian blue) stain (Fig. 2). In the upper endoscopy was also evident a 12 mm ulcer with clean base in the anterior wall of the second part of duodenum (Fig. 3). Biopsies of duodenal mucosa revealed an area of ulceration with extracellular crystalline and fibrillar iron deposition (Perls’ positive) over granulation tissue associated with foreign body reaction (Fig. 4). Cytomegalovirus (CMV) infection was ruled out after negative results in the immunohistochemical and molecular biology