University of Connecticut Health Center Plantsville, CT, United States
Teresa Da Cunha, MD1, Sanket Patel, DO2, Faripour Forouhar, MD1, Haleh Vaziri, MD3 1University of Connecticut Health Center, Farmington, CT; 2University of Connecticut Health Center, Hartford, CT; 3University of Connecticut, Farmington, CT
Introduction: Diarrhea in patients with acquired immunodeficiency syndrome (AIDS) is not uncommon. The immunocompromised status may lead to opportunistic infections if not adequately treated. When the diagnosis is unclear, an endoscopic evaluation may be necessary. We present a case of chronic diarrhea, with colonic biopsies suggesting Crohn's disease, and the importance of further investigation to rule out infectious causes.
Case Description/Methods: A 55-year-old male with AIDS (recently started on HAART), Hodgkin’s lymphoma (in remission) and COPD was referred to gastroenterology for weight loss, chronic diarrhea, and bloating for the past 6 months. Work up including routine stool culture and C. Difficile tests were negative. Colonoscopy showed a stricture in the transverse colon and ulcerated nodules in the entire examined colon. (Fig.1) The pathology results from the transverse colon revealed ulcerated epithelium, chronic inflammation with crypts distortion containing epithelioid microgranulomas. The left colon biopsies also demonstrated cryptitis associated with a conglomerate of microgranulomas. Pathology was reported as highly suspicious for Crohn’s disease. Extensive intra-abdominal lymphadenopathy was seen on CTE. Given a high index of suspicion for an infectious etiology, stool was sent for AFB, showing negative stain but a positive culture for mycobacterium species. The patient was empirically started on azithromycin and ethambutol for presumed Mycobacterium avium complex (MAC) while awaiting final speciation of mycobacterium.
Discussion: New onset of Inflammatory bowel disease (IBD) is exceedingly rare in patients with AIDS. This is likely due to the immunocompromised state allowing improvement of IBD. It is also important to note that intestinal infection by mycobacterium species can lead to very similar histopathological findings as Crohn’s as seen in our case. A combination of clinical and histological characteristics have been used to differentiate the two entities but without AFB stains, it is extremely difficult. Our patient had extensive lymphadenopathy that can be suggestive of infection by MAC. It is of utmost importance to rule out infectious causes of diarrhea in this patient population despite pathology findings implicating IBD, as further immunosuppression in these patients can be lethal.
Figure: Fig.1 - (A) ulcerated nodules visualized over the entire examined colon on colonoscopy; (B) stricture in the transverse colon seen during colonoscopy; (C) histopathology of the descending colon biopsy with H&E stain showing microgranulomas; (D) histopathology of the descending colon biopsy with H&E stain showing crypt distortion and chronic inflammation.
Teresa Da Cunha indicated no relevant financial relationships.
Sanket Patel indicated no relevant financial relationships.
Faripour Forouhar indicated no relevant financial relationships.
Haleh Vaziri indicated no relevant financial relationships.
Teresa Da Cunha, MD1, Sanket Patel, DO2, Faripour Forouhar, MD1, Haleh Vaziri, MD3. P0205 - Intestinal Granulomas: Not Always Crohn’s Disease, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.