Purpose: A 74-year-old woman was admitted with unrelenting diarrhea and progressive malaise over a 2 week period. Stools were watery, voluminous, non-bloody and worsened after oral intake. She had associated abdominal cramping but denied fevers, chills, rashes, oral lesions, ill contacts, recent antibiotic use, travel or ingestion of raw or undercooked foods. Home medications included Prilosec, simvastatin, metoprolol, losartan-HCTZ, and aspirin. Physical exam revealed temperature 37.8 °C, pulse 90 bpm, respirations 13, BP 127/56 and oxygen saturation of 96% on ambient air. She appeared tired, weak, and with dry oral mucous membranes and depressed neck veins. The remainder of the exam was unremarkable. Initial lab studies showed albumin 2.4 gm/dL (3.4-5.0), total protein 5.3 gm/dL (6.4-8.2), potassium 3.3 mmol/L (3.4-5.1), chloride 109 mmol/L (98-107), magnesium 1.3 mg/dL (1.6-2.4), and phosphorus 1.9 mg/dL (2.4-4.7). CBC and CMP were otherwise unremarkable. Urinalysis was negative for protein. Her medications were held as she received supportive management and hydration. Clostridium difficile PCR, viral pathogens, ova and parasite, and enteric pathogens were negative. Colonic and terminal ileum biopsies were normal. Serology for celiac screening was negative. She improved quickly, tolerated general diet, and was discharged home. Within 24 hours, she was readmitted with recurrent symptoms. Given persistence and severity of symptoms, extensive workup ensued. Stool potassium was 12.5 mEq/L and sodium 142 mEq/L, consistent with secretory diarrhea. Fecal fat stain was negative. 24 hour urine 5HIAA level was 21 mg/g (< 14) and serum serotonin was 302 ng/mL (50-200). Chromogranin A and gastrin levels were normal. CT scan of the chest, abdomen and pelvis were negative. An octreotide scan showed soft tissue uptake in the left trochanteric region, however, MRI of the hip revealed this was due to degenerative changes. She again responded quickly to supportive care and was discharged home, only to return a third time, six days later, with profuse diarrhea. Clinical history was re-evaluated and patient remembered a recent medication change from atorvastatin to simvastatin 2 days before initial events. As before, symptoms abated when medications were held in the hospital. A medication challenge with simvastatin 20 mg was administered and four hours later, symptoms were reproduced with multiple, profuse, watery bowel movements. She has remained symptom free since discontinuation. Protein-losing enteropathy has been published in one patient, but generally transient diarrhea induced by simvastatin is <3%. This case represents a rare presentation of severe secretory diarrhea, which has not been previously reported.
Search from 250 M+ research papersSearch from 250 M+ research papers
Open Access
Feb 26, 2014
A Sporn + 5
