Introduction: Attenuated familial adenomatous polyposis (AFAP) is a rare, less-aggressive subset of familial adenomatous polyposis (FAP). We report a rare case of AFAP presenting as symptomatic iron deficiency anemia. Case Report: A 61-year-old female with a history of iron deficiency anemia, on iron replacement therapy, with a base line hemoglobin of 8.5 g/dL presented with complaints of fatigue and a 26-pound weight gain over a 6-month period. The patient denied melena, hematochezia, hematemesis and change in stool caliber, color or shape. The patient reports a family history of unknown colon cancer in her father at age 76 years, mother at age 78 years, and sister at age 48 years. Physical exam findings are unremarkable. Labs: hemoglobin 5.8 g/dL, WBC 10.3 K/uL, Fe 21 ug/dL, Fe% Sat 5%, and TIBC 419 ug/dL. Colonoscopy was positive for sporadic polyps (2-3) in the rectum, sigmoid, and descending colon, innumerable polyps (estimated to be less than 100) in the cecum, transverse colon, and ascending colon, culminating into a 10-cm-long circumferential ulcerated mass beginning distal to the ileocecal valve. Biopsies were positive for invasive adenocarcinoma. The patient elected to undergo treatment with colectomy. Discussion: AFAP is a subset of FAP. FAP is a rare manifestation of colorectal adenomatous disease in which without treatment will lead to a lifetime cancer risk as high as 100%. FAP typically presents as hundreds to thousands of adenomas in the colon and rectum, usually before the age of 30 years, with progression to cancer before the patient is 40 years old. FAP is responsible for less than 1% of all gastrointestinal cancers. AFAP is less aggressive than FAP, in that the patient develops less than 100 colorectal polyps and is usually diagnosed in their 40s with progression to colorectal cancer in their 60s. Like FAP, AFAP patients have a lifetime cancer risk as high as 100%. Recent studies have demonstrated that AFAP is an autosomal dominant disease that may be caused by mutations in the adenomatous polyposis coli gene (APC) or the mutY homologue gene (MUTYH), but the exact mechanism of the disease in unknown. AFAP most commonly presents with vague abdominal complaints, constipation, lower abdominal pain, or anemia. AFAP is most commonly diagnosed by colonoscopy. Prophylactic colectomy is recommended for the prevention of progression to colorectal cancer, however, it has been reported that AFAP can have extracolonic manifestations, such as gastroduodenal lesions. Conclusion: AFAP is a rare, less-aggressive subtype of FAP, characterized by fewer polyps and with an older age of onset, diagnosis, and progression to colorectal cancer.
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