An Unexpected Masquerader: A Case of Acute Fulminant Colitis Secondary to Ulcerative Colitis

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Inflammatory bowel disease (IBD) has a bimodal age distribution with a second peak between 50 and 80 years. We report a case of fulminant colitis in a 74-year-old Caucasian Male presenting with diarrhea and intermittent left lower quadrant pain. His medical history was pertinent for an episode of acute complicated sigmoid diverticulitis with perforation, and abscess formation 2-months prior. A CT-guided drainage was performed then and he was treated with a course of piperacillin-tazobactam and amoxicillin-clavulanic acid. A sigmoidoscopy was performed 4 weeks later and findings included a sigmoid stricture, pseudo-membranes and a 4 cm sigmoid tubular adenoma; which was resected. A Clostridium Difficile test was positive and the patient was started on oral vancomycin. The patient reported worsening of his symptoms and developed hematochezia. His repeat diagnostic evaluation was remarkable for a mild neutrophilic leukocytosis of 13,200 cells/mm3, marked lactic acidosis and negative C. Difficile testing. A CT-scan of the abdomen revealed diffuse colitis and a repeat flexible sigmoidoscopy demonstrated ischemic changes and multiple areas of friable mucosa. The patient further deteriorated and underwent a total colectomy with ileostomy given concern for ischemic colitis. Saccharomyces Cervisiae IgA and IgG titers were positive and ANCA testing was negative. Pathology results revealed chronic active colitis with cryptitis, crypt abscesses, and absence of granulomas with multiple diverticula. Morphology was consistent with a diagnosis of fulminant colitis secondary to ulcerative colitis. The patient underwent a complicated post-operative course with the development of postoperative pneumonia, pulmonary edema and ventilator dependent respiratory failure requiring tracheostomy placement. This case serves to illustrate the importance of recognizing the bimodal distribution of inflammatory bowel disease (IBD), entertaining the diagnosis in elderly patients presenting with colitis, and the importance of a multi-disciplinary approach to establishing a diagnosis of IBD involving clinicians and pathologists. The presence of an anchoring bias to the diagnosis of acute diverticulitis when the first sigmoidoscopy was performed and the attribution of the patient's colitis to C. Difficile colitis and later ischemic colitis led to a late diagnosis of IBD with significant morbidity noted. The case also highlights the utility of serologies in diagnosing IBD.