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Clinical Images

101 Dalmatians: What Are These Dots?

An 84 year-old female with Barrett’s esophagus and remote history of right toe amputation due to metastatic carcinoma was admitted for failure to thrive, presenting as nausea, vomiting, anorexia, and constipation with an associated episode of bloody emesis. Initial laboratory data was consistent with anemia (hemoglobin of 9.8g/dL and hematocrit of 27.9%, down from a baseline of 11g/dL and 32% four months prior). Further work up showed anemia of chronic disease with iron level of 14 ug/dL. She underwent upper endoscopy which showed a lesion within her known Barrett’s esophagus (Figure 1).  There were numerous variable-sized, black-pigmented mucosal lesions also noted in the duodenum and ileum (Figures 2 and 3). 


Figure 1



Figure 2



Figure 3


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1. Uchiyama S, Imamura N, et al. Late recurrence of malignant melanoma in the duodenum. Hepatogastroenterology. 2008 Sep-Oct; 55(86-87):1619-21.
2. Chang AE, Karnell LH, Menck HR. The National Cancer Data Base report on cutaneous and noncutaneous melanoma: a summary of 84,836 cases from the past decade. The American College of Surgeons Commission on Cancer and the American Cancer Society. Cancer 1998; 83:1664.

Author Biographies

Tokunbo Ajayi is a chief resident in the Department of Medicine at North Shore Medical Center (NSMC) in Salem, Massachusetts.  He attended medical school at the Obafemi Awolowo University, Ile-Ife, Nigeria. 

Nicholas Karamitsios is a gastroenterologist in the Department of Gastroenterology at North Shore Medical Center (NSMC) in Salem, Massachusetts.  He attended the Boston University School of Medicine and completed his gastroenterology fellowship at the University of Massachusetts Medical Center.

Han Jeppesen is the Director of Hospital Medicine at North Shore Medical Center (NSMC) in Salem, Massachusetts.   He completed his internal medicine residency at the University of Minnesota Medical School.