An Unexpected Cause of Chronic Diarrhea

Abstract

Question: A 59-year-Italian old man presented to our hospital with a 2-year history of Crohn’s colitis refractory to treatment. Colitis had worsened and diarrhea became frankly bloody after 6 months, despite treatment combinations of topical and systemic mesalazine, prednisone, and azathioprine. In the patient’s notes, there was no history of travel abroad. At the time of presentation in our hospital, the patient had a hemoglobin of 11.6 (normal, 13-16) and white blood cell count revealed mild leukocytosis of 11,100/mm (62.6% neutrophils, 26% lymphocytes, 8.9% monocytes, 1.7% eosinophils, 0.8% basophils). The inflammatory markers were moderately increased (C-reactive protein, 2 mg/dL; normal, 0-0.5). Platelet count, creatinine, urinalysis, and fecal calprotectin were normal. Colonoscopy showed few ulcerations burrow deep into the cecal bowel wall, with other superficial ulcers and multiple erosions and mild reddening of the rectum and distal sigmoid colon. The ileum was not involved. Multiple biopsies were taken from the cecum (Figure A) and from distal sigmoid colon and rectum. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.