Gastroenterology clinical image challenge: A 31-year-old man presented to the emergency department complaining of bloody mucoid diarrhea of three weeks’ duration, associated with worsening diffuse colicky abdominal pain, weight loss and chills. His medical history includes plaque psoriasis being treated with ixekizumab for the last three months before presentation. He admits smoking for the last 10 years. On presentation, the patient was hemodynamically stable and afebrile.
His physical examination revealed left lower quadrant tenderness with no rebound or guarding. His initial laboratory results showed a white cell count of 14,000/mm3 (granulocytes 67 percent, lymphocytes 19 percent, monocytes 10 percent), hemoglobin of 14.8 g/dL, platelets of 359/mm3 and a normal liver profile. Initial laboratory tests and stool culture were negative. A computed tomographic scan of his abdomen with intravenous contrast disclosed pericolonic inflammation involving predominantly sigmoid and descending colon, suggestive of colitis. A flexible sigmoidoscopy was performed initially to show severe ulcerative proctosigmoiditis with a spread of yellow pseudomembranes, suggestive of superimposed Clostridium difficile-associated infection. Pathology thereafter confirmed our presumptive diagnosis.
The patient was immediately started on intravenous metronidazole, oral vancomycin and parenteral steroids. Initially, he showed mild improvement, however two weeks later; bloody diarrhea recurred along with worsening abdominal pain, anorexia, weight loss and severe hypoalbuminemia. Repeat flexible sigmoidoscopy illustrated deep ulcers with heaped up margins and prominent surrounding edema and erythema (Figure). Random biopsies were obtained from the inflamed mucosa as well as separately from the ulcers.
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