Electronic Clinical Challenges and Images in GI An Unexpected Explanation for Exhaustion Gianluca Granà,* Giulio Trecco, ‡ and Simonetta Friso ‡ *Department of Pathology and Diagnostics and ‡ Department of Medicine, University of Verona School of Medicine, Verona, Italy Question: A 31-year- old Senegalese man with no significant past medical history pre- sented with progressive weight loss, fatigue, and gluteal pain. He had no family or per- sonal history of neo- plastic disease. On ad- mission, physical exam- ination showed apy- rexia, a spontaneously drained right gluteal abscess, oral mucositis, angular cheilitis, spleno- megaly, diffuse lymph node enlargement, koilonychia and a mild mitral murmur. Chest examination was not significant. His body mass index was 16 kg/m 2 . Laboratory tests revealed a severe microcytic, hypochromic, sideropenic anemia (hemoglobin, 4.1 g/dL; mean corpuscular volume, 60 fL; mean corpuscular hemoglobin, 20 pg; hematocrit, 18%; ferritin, 4 ng/mL; and transferrin saturation, 4%). Serum chemistries for thyroid, liver, and kidney function tests were all normal with no biochemical signs of systemic inflammation. Serology tests for infectious diseases, including HIV, and cultures from the gluteal wound were negative. Immunologic profile, antigliadin antibodies, and anti-endomysial antibodies were also negative. Chest x-ray showed an enlarged heart profile and heart ultrasonography demonstrated a global severe myocardial hypokinesis. Colonoscopy was negative. The esophagogastroduodenoscopy revealed a smooth, thin extension of the esophageal tissue (Figure A) that was clearly detectable also by barium-swallow esophagography (Figure B). What do all of these findings suggest? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2012 by the AGA Institute 0016-5085/$36.00 doi:10.1053/j.gastro.2011.11.049 GASTROENTEROLOGY 2012;142:e5– e6