S3356 What Came First, the IBD or the Worm?

Abstract

INTRODUCTION: At the turn of the 21st century, inflammatory bowel disease (IBD) became a global issue. Patients present with diarrhea, hematochezia, and colicky abdominal pain. Diagnosis is made based on clinical presentation, endoscopy and biopsy results. Helminths have been used in the therapy of IBD. CASE DESCRIPTION/METHODS: A 63-year-old female presented with periumbilical abdominal pain, vomiting and hematochezia of one week. Family history notable for Crohn’s disease in her mother and a travel history to Peru 1 year prior to presentation. Labs showed neutrophil predominant leukocytosis with WBC 23000/uL. Stool culture was negative, including Clostridium difficile stool PCR. Computed tomography (CT) scan of the abdomen and pelvis showed extensive circumferential thickening of the colonic wall with peri-colonic inflammatory changes. She was diagnosed with infectious colitis and discharged on a course of ciprofloxacin and metronidazole. She presented a week later with recurrent symptoms. Absolute eosinophil count 149/uL. Erythrocyte sedimentation rate (ESR) 55 mm/hr and C-reactive protein (CRP) 15 mg/L. Stool calprotectin 95 mcg/g. Stool cultures were again unrevealing. Repeat CT abdomen and pelvis showed segmental wall thickening and peri-colonic stranding from the distal descending colon to the rectum. Colonoscopy notable for segmental inflammation from the rectum to the cecum. Pathology reported this as focal architectural distortion with granulation tissue in the lamina propria. Additionally, there were discontinuous areas of nonbleeding ulcerated mucosa in the sigmoid colon, hepatic flexure and ascending colon with pathology consistent with ischemic colitis. On follow up, she reported generalized urticarial rash, persistent altered bowel habits and weight loss. Repeat colonoscopy showed healing of previous segmental colitis but notable for parasites in the cecum. This was reported as Trichuris trichiura and she was treated with mebendazole with complete clinical resolution. DISCUSSION: The diagnosis of IBD is based on clinical presentation, inflammation on endoscopy and chronic changes on biopsy. Our case describes inflammatory changes on endoscopy and biopsy which had spontaneously resolved; but also, with an incidental diagnosis of Trichuris infection. It poses an interesting question of whether the initial presentation concerning for possible IBD was due to the helminthic infection or whether the helminthic infection coincided with the colitis and was therapeutic against existing colitis.Figure 1.: Pathology of sigmoid colon remarkable for extensive erosion with fibrinopurulent exudate, fibrosis of lamina propria and atrophic glands, consistent with ischemic changes image showing changes of ischemic changes.Figure 2.: Parasite noted on colonoscopy.