Presentation of Case



Dr. Amulya Nagarur (Medicine): An 80-year-old man with end-stage renal disease, type 2 diabetes mellitus, peripheral arterial disease, hypertension, coronary arteriosclerosis, congestive heart failure, abdominal aortic aneurysm, hyperlipidemia, and gout was admitted to this hospital because of anorexia, weight loss, abdominal pain, diarrhea, and an ileocecal mass.

Three years before this admission, the patient had been seen in the emergency department of this hospital because of neck pain. Computed tomography (CT) of the neck revealed evidence of degenerative disk disease of the cervical spine and a pulmonary nodule (8 mm in diameter) in the left upper lobe.

Figure 1. Positron-Emission Tomographic and CT Scans.



An 18F-fluorodeoxyglucose–positron-emission tomographic (FDG–PET) scan (Panel A) shows increased FDG uptake in a nodule in the left upper lobe (arrowhead) and in the region of the ileocecal valve (arrow). A corresponding axial CT scan (Panel B) shows a 1-cm nodule in the left upper lobe (arrowhead). A corresponding coronal CT scan (Panel C) shows wall thickening of the terminal ileum and ileocecal valve (arrow) and adjacent fat stranding, as well as an infrarenal aortic aneurysm (asterisk). Positron-Emission Tomographic and CT Scans.AnF-fluorodeoxyglucose–positron-emission tomographic (FDG–PET) scan (Panel A) shows increased FDG uptake in a nodule in the left upper lobe (arrowhead) and in the region of the ileocecal valve (arrow). A corresponding axial CT scan (Panel B) shows a 1-cm nodule in the left upper lobe (arrowhead). A corresponding coronal CT scan (Panel C) shows wall thickening of the terminal ileum and ileocecal valve (arrow) and adjacent fat stranding, as well as an infrarenal aortic aneurysm (asterisk).

Dr. Shaunagh McDermott: Three months after that initial visit, follow-up CT of the chest was performed, and the nodule in the left upper lobe had not changed in size. Five months after the initial visit, combined 18F-fluorodeoxyglucose–positron-emission tomography and CT (FDG–PET–CT) revealed that the pulmonary nodule had increased in size to 1 cm in diameter, was tethered to the overlying pleura in the left upper lobe, and had increased FDG uptake; a contiguous nodule (7 mm in diameter) with increased FDG uptake and new nodules in the right middle lobe were also present. In addition, there was intense diffuse FDG uptake in the stomach, as well as wall thickening of the most distal aspect of the terminal ileum and the cecum in the region of the ileocecal valve, with adjacent inflammatory fat stranding (Fig. 1).

Dr. Nagarur: Lung biopsy, upper endoscopy, and colonoscopy were recommended, but the patient declined to undergo these procedures. Approximately 9 months after the initial visit, induration (8 mm in diameter) developed at the site of a tuberculin skin test that had been performed during a hemodialysis appointment at an outpatient care unit. Chest radiography was performed; pulmonary lesions were not noted.

Eleven months after the initial visit (25 months before this admission), severe abdominal pain in the right lower quadrant and pain in the right flank developed acutely, and the patient presented to the emergency department at this hospital. Imaging studies were obtained.

One month later, a physical examination was normal. A complete blood count and white-cell differential count were normal, as were blood levels of electrolytes, calcium, glucose, total protein, albumin, globulin, free thyroxine, and thyrotropin and results of renal- and liver-function tests; testing for H. pylori infection and celiac disease was negative. Abdominal radiography was performed.

Figure 2. Serial CT Scans Obtained over a 30-Month Period.



Coronal CT scans that were obtained over a 30-month period (Panels A through E) show persistent thickening of the terminal ileum and ileocecal valve (arrows in all panels) and adjacent fat stranding. There is high-attenuation fluid in the retroperitoneum (Panel A, asterisk), a finding consistent with hemorrhage due to a right renal subcapsular hematoma (not shown). There is also an infrarenal aortic aneurysm (Panel B, asterisk), which shows endovascular repair on follow-up images (Panels C and D). Serial CT Scans Obtained over a 30-Month Period.Coronal CT scans that were obtained over a 30-month period (Panels A through E) show persistent thickening of the terminal ileum and ileocecal valve (arrows in all panels) and adjacent fat stranding. There is high-attenuation fluid in the retroperitoneum (Panel A, asterisk), a finding consistent with hemorrhage due to a right renal subcapsular hematoma (not shown). There is also an infrarenal aortic aneurysm (Panel B, asterisk), which shows endovascular repair on follow-up images (Panels C and D).

Dr. McDermott: CT of the abdomen and pelvis, performed after the intravenous administration of contrast material (Fig. 2A), revealed a hematoma in the right anterior pararenal space that arose from a subcapsular hematoma in the right kidney, with extravasation of blood into the retroperitoneal space. In addition, the soft-tissue mass at the ileocecal junction had increased in size.

Figure 3. Colonoscopic Image.



An initial colonoscopy was performed approximately 25 months before the current admission. A nonobstructive fungating mass (4 cm by 2 cm) was visualized at the ileocecal valve. (Photograph courtesy of Drs. Ruma Rajbhandari and Braden Kuo.) Colonoscopic Image.An initial colonoscopy was performed approximately 25 months before the current admission. A nonobstructive fungating mass (4 cm by 2 cm) was visualized at the ileocecal valve. (Photograph courtesy of Drs. Ruma Rajbhandari and Braden Kuo.)

Dr. Nagarur: The patient was admitted to the hospital, and coil embolization of the right renal artery was performed. On the fourth hospital day, a colonoscopy was performed, and a nonobstructive fungating mass (4 cm by 2 cm) was visualized at the ileocecal valve (Fig. 3). Examination of a biopsy specimen of the mass showed severely active chronic colitis with fibrinopurulent exudate. On the 11th hospital day, colonoscopy was repeated and upper endoscopy was performed. In addition to the ileocecal mass, there were a few small inflammatory nodules with a patchy distribution in the lower two thirds of the esophagus, an oozing cratered ulcer in the gastric body with a visible vessel that was clipped, a few nonbleeding superficial ulcers in the gastric antrum, and diffuse, moderately erythematous mucosa in the duodenal bulb. Histopathological examination of biopsy specimens revealed erosive gastritis with reactive foveolar hyperplasia and markedly active chronic ileitis and ileocolitis with ulceration and nonnecrotizing granulomas; no fungal forms or acid-fast bacilli were seen. The patient was discharged home while taking omeprazole.

Eight weeks after that discharge (approximately 23 months before this admission), the patient was seen in the gastroenterology clinic at this hospital. He reported having two or three bowel movements each day, with formed stools and without blood or pain during defecation. He had a reduced appetite but no abdominal pain. The weight was 65.3 kg (decreased from 78.0 kg 3 years earlier), and the abdominal examination was normal. The erythrocyte sedimentation rate was 67 mm per hour (reference range, 0 to 13), and the C-reactive protein level was 55.5 mg per liter (reference value, <8.0). The dose of omeprazole was increased.

Approximately 19 months before this admission, 2 weeks after the patient was discharged from a hospital stay for pacemaker placement, he was seen in the primary care clinic with a 5-day history of diarrhea, lower abdominal pain, and tenderness. The weight was 59.3 kg. A stool culture was negative for enteric pathogens, and a test for Clostridium difficile was positive. A 10-day course of oral metronidazole was prescribed; the frequency of diarrhea initially decreased but returned to three or four times a day after the medication was stopped. A 14-day course of oral vancomycin was prescribed, and the symptoms abated.

Table 1. Laboratory Data.

Laboratory Data.

Sixteen months before this admission, severe abdominal pain in the right lower quadrant developed acutely, and the patient presented to the emergency department at this hospital. He reported feeling weak; the right lower quadrant was tender on palpation. Laboratory test results are shown in Table 1. Additional imaging studies were obtained.

Dr. McDermott: CT of the abdomen and pelvis, performed after the intravenous administration of contrast material, revealed persistent irregular wall thickening of the terminal ileum, with mild adjacent inflammatory fat stranding (Fig. 2B).

Dr. Nagarur: Hemodialysis was performed, and the patient was admitted to the hospital. Ciprofloxacin and metronidazole were administered, and the abdominal pain improved during the next 3 days. A stool culture and examinations for ova and parasites were negative, and a test for C. difficile was positive; ciprofloxacin was discontinued, and the patient was discharged with a prescription for a 14-day course of oral metronidazole.

Thirteen months before this admission, the patient returned to the gastroenterology clinic. He reported that he had had three or four loose, nonbloody bowel movements each day for several weeks, with associated generalized abdominal pain. His appetite continued to be reduced, and he felt weak and fatigued. The weight was 55.8 kg, and the abdominal examination was normal. Laboratory test results are shown in Table 1.

Dr. McDermott: CT angiography of the abdomen and pelvis had been performed 2 days before this visit to the gastroenterology clinic, during routine follow-up after a recent endovascular procedure for the repair of an abdominal aortic aneurysm. The imaging studies revealed an increase in the circumferential wall thickening of the terminal ileum and cecum (Fig. 2C).

Dr. Nagarur: A diagnosis of Crohn’s disease was considered. Treatment with prednisone and methotrexate was recommended, but the patient declined the treatment. Eleven weeks before this admission, generalized weakness, diffuse abdominal discomfort and tenderness, and hypotension developed during an outpatient hemodialysis session. The patient was admitted to the hospital, and fever (to a temperature of 38.4°C) developed. Cefepime and vancomycin were administered intravenously. Laboratory test results are shown in Table 1.

Dr. McDermott: CT of the abdomen and pelvis revealed increased diffuse wall thickening of the terminal ileum and cecum, with persistent mesenteric fat stranding and lymphadenopathy (Fig. 2D).

Dr. Nagarur: By the third hospital day, the fever had resolved and the abdominal pain had improved but diarrhea had developed; a test for C. difficile was again positive. Cefepime and vancomycin were discontinued. The patient was discharged home with prescriptions for budesonide, a 4-week course of ciprofloxacin and metronidazole, and a 6-week tapering course of oral vancomycin.

Three and a half weeks before this admission, the patient underwent endarterectomies of the right common femoral artery and the right superficial femoral artery at this hospital. Diarrhea and tenderness of the right lower quadrant developed postoperatively. The patient was uncertain whether he had been taking the budesonide and oral vancomycin that had been prescribed during his most recent hospitalization. Urinalysis revealed cloudy urine with 3+ leukocyte esterase, 3+ occult blood, 2+ albumin, and negative nitrites by dipstick, as well as more than 100 white cells and 20 to 50 red cells per high-power field. Other laboratory test results are shown in Table 1.

Dr. McDermott: CT of the abdomen revealed persistent circumferential wall thickening of the terminal ileum and cecum and extensive adjacent fat stranding that had increased slightly since previous imaging studies had been obtained (Fig. 2E).

Dr. Nagarur: On the sixth hospital day, a bowel movement contained blood; a test for C. difficile was negative. The patient was discharged home on the seventh hospital day with prescriptions for budesonide, a 7-day course of ciprofloxacin, and a tapering course of oral vancomycin.

During the 24 hours after discharge, the patient had four episodes of diarrhea containing bright red blood and returned to the emergency department of this hospital. He reported abdominal pain in the right lower quadrant and fatigue. The temperature was 38.3°C, and the abdomen was tender in the right lower quadrant. While the patient was in the emergency department, he had two bowel movements that were loose and melanotic. A stool culture, an assay for Shiga toxin, and examinations for ova and parasites were negative. Other laboratory test results are shown in Table 1.

The patient was admitted to the hospital. Pantoprazole was administered, and a series of hematocrit measurements showed minimal change. By the fourth hospital day, the melena had resolved and the abdominal pain had lessened, although diarrhea persisted. The patient was discharged home on the sixth hospital day.

On the day of this admission, the patient was brought to the emergency department of this hospital by ambulance because of shortness of breath. He reported progressive fatigue and weakness that had persisted since the most recent hospitalization; on the day of this admission, he had been unable to get out of bed. Medications included aspirin, metoprolol, atorvastatin, cilostazol, budesonide, omeprazole, allopurinol, sevelamer carbonate, several vitamins, darbepoetin alfa, tramadol, acetaminophen, and vancomycin. Adverse drug reactions included cough with lisinopril, edema with nifedipine, confusion with morphine and oxycodone, and rash with hydrochlorothiazide, felodipine, and clonidine. The patient had emigrated from Southeast Asia 22 years earlier and now lived in an urban area of New England with his wife and daughter. His family history was negative for gastrointestinal, renal, and immunodeficiency diseases. He drank alcohol rarely and did not smoke cigarettes or use illicit drugs.

On examination, the patient appeared thin and chronically ill. The temperature was 36.7°C, the pulse 104 beats per minute, the blood pressure 114/65 mm Hg, the respiratory rate 16 breaths per minute, and the oxygen saturation 97% while he was breathing ambient air. Crackles were heard in the posterior lower lung fields on auscultation. The abdomen was mildly tender, and the legs were edematous. Laboratory test results are shown in Table 1. Chest radiography revealed changes consistent with mild interstitial pulmonary edema, with small bilateral pleural effusions and a confluent opacity in the left lower lobe. Hemodialysis was performed. The shortness of breath resolved, but weakness and fatigue persisted. The patient was admitted to the hospital.

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