Hemorrhagic Colitis as a Manifestation of Wegenerʼs Granulomatosis: Think Outside the Box

Abstract

Case Report: A 37-year-old African American male presented to our institution with a 2 week history of diffuse crampy abdominal pain associated with frequent watery bowel movements and low grade fever. On presentation he was tachycardic, febrile and abdominal exam was unremarkable. Blood work revealed normocytic anemia, leucocytosis, coagulopathy, elevated ESR, CRP and hypokalemia and was started on intravenous antibiotics. Chest X-ray at admission revealed multiple cavitary lesions. Echocardiogram, stool studies, pancultures, serum Quantiferon, HIV test and urinalysis were unrevealing. CT chest showed lung opacities suspicious for septic emboli or neoplastic process and was started on anticoagulation that precipitated rectal bleeding while awaiting lung biopsy. Colonoscopy revealed large, deep, skipped, exudative ulcerations throughout the colon, pathology significant for chronic inflammation with crypt distortion. Due to the persistence of fever on antibiotics, steroids were started for possible autoimmune etiology. CT guided lung biopsy revealed suppurative granulomas with small vassel vasculitis, highly suspicious for Wegener's granulomatosis (WG) in the setting of elevated C-ANCA. Repeat colonoscopy for rectal bleeding revealed improvement in ulcerations with antibiotic and steroid use. Thoracoscopic lung biopsy revealed thrombotic arteriopathy, vascular intimal thickening indicative of vasculitis. He was discharged home on steroids having refused cyclophosphamide. He was asymptomatic at 6 months follow-up. Discussion: We present a unique case of a patient with pulmonary nodules and hemorrhagic colitis consistent with WG. Intestinal manifestations as an initial presentation of WG are rarely reported. As intestinal involvement is rare in WG, an important differential is inflammatory bowel disease (IBD), though lung manifestations are rare in IBD. Although our initial suspicion was Crohn's disease based on colonoscopic findings and pathology results, further investigation of the patient's lung pathology confirmed a systemic vasculitic process consistent with WG. Conclusion: Combined pulmonary and intestinal findings carry a small list of differentials, of which vasculitis including WG should be high on the differential.