2074 Small Bowel and Colonic Ulcerations in a 19-Year-Old Male With Disseminated Adenovirus: An Atypical Presentation of Inflammatory Bowel Disease?

Abstract

INTRODUCTION: Enteritis and colitis have wide differential diagnoses including inflammatory bowel disease, infections, and ischemia. We present an unusual case of an 19-year-old male who presented to the intensive care unit with disseminated adenovirus and required a prolonged hospital course who went on to develop ongoing symptoms of non-bloody high output diarrhea. A colonoscopy was performed and demonstrated significant right sided colonic disease with ulcerations in a patchy distribution as well as small bowel inflammation of unclear etiology, however given the appearance was likely felt to be a new presentation of Crohn’s disease. CASE DESCRIPTION/METHODS: A 19-year-old male with a history of childhood asthma presented with 1 week of fatigue, cough, and sore throat. Patient was admitted to the intensive care unit for septic shock and acute respiratory distress syndrome secondary to disseminated adenovirus, requiring intubation and ultimately extracorporeal membrane oxygenation. Patient’s course was complicated by failure of enteral feeds requiring total parenteral nutrition and acute renal failure requiring CVVH and hemodialysis. On hospital day 14 patient began having non-bloody high output diarrhea. C. difficile toxin and stool cultures were negative. Fecal calprotectin was elevated to 681 mg/kg. A colonoscopy was performed revealing diffuse inflammation with linear erosions, mucus and deep ulcerations in the terminal ileum in addition to patchy inflammation characterized by erythema, cobblestoning, and deep ulcerations from the transverse colon to the cecum, all concerning for Crohn’s disease versus viral etiologies. Patient was empirically started on steroids with significant improvement of diarrhea. Pathology showed acute neutrophilic inflammation and chronic lymphohistiocytic inflammation of the mucosa without granulomas with the differential diagnosis felt to be viral enteritis or atypical inflammatory bowel disease. DISCUSSION: Crohn’s disease is diagnosed by clinical, endoscopic, and pathologic findings. However, the pathogenesis of IBD remains unclear. The two-hit hypothesis, where genetic predisposition and environmental factors cause a cascade pathway to IBD has been proposed as a likely mechanism. Factors including pathogens and diet, like adenovirus infection and TPN in our case, may be environmental triggers for IBD. In addition, this case highlights the need to always consider IBD in an acutely ill person even when treatments such as antibiotics and TPN may be other culprits for diarrhea.