Lymphocytic Colitis in a Two Year Old Presenting with Chronic Diarrhea

Abstract

Lymphocytic colitis (LC) is a subtype of microscopic colitis characterized by chronic, non-bloody, watery diarrhea, normal colonoscopy, and abnormal histopathological findings defined by >20 intraepithelial lymphocytes per 100 enterocytes. Defined in 1976, it has traditionally been a disease of adulthood with the mean age of diagnosis of >50 years. Over the past decade, numerous reports have suggested that LC may present at any age with increasing incidence in children. We describe a 2-year-old girl with LC who presented with chronic diarrhea. To our knowledge, she is the youngest described patient with LC. A 2-year-6-month-old girl presented with episodic crampy abdominal pain, nonbloody, nonmucoid, watery diarrhea and decreased growth velocity. These cycles occurred every 1-2 months since 18 months of age. Stool cultures, C difficile, ova and parasites were negative. Celiac screen, RAST for food allergies, and standard blood tests were all within normal limits. CT abdomen was normal. EGD and colonoscopy appeared normal. Histopathology of esophagus, stomach, duodenum, and terminal ileum were normal. However, biopsies of all sections of colon and rectum showed marked intraepithelial lymphocytosis within the lamina propria that was consistent with LC. She was started on sulfasalazine (25 mg/kg/day) with initial success marked by decreased stooling and decrease in abdominal pain. The mother discontinued the medication and symptoms returned almost immediately. Three weeks after discontinuation of sulfasalazine, patient returned to clinic due to increased symptoms. She was restarted on sulfasalazine (40 mg/kg/day) with near complete resolution of abdominal pain, having 1-2 formed stools daily, and two-month interval weight gain of 1.5 kg. The cause of LC is unknown although bacteria, viruses, non-steroidal anti-inflammatory drugs, or autoimmunity have been implicated as inciting factors. Treatment is aimed at decreasing diarrhea symptoms and inflammation. Bulking agents improve diarrhea and anti-inflammatory agents such as sulfasalazine and corticosteroids have been used with success. While LC is a rare disease in children, it should be considered in pediatric patients with chronic non-bloody diarrhea.