PHOTO QUIZ Anthony Amoroso, Section Editor
Chronic Abdominal Pain and Intestinal Obstruction in a 24-Year-Old Woman (See pages 1035–6 for the Answer to the Photo Quiz.)
A 24-year-old woman from Saudi Arabia with type I diabetes mellitus presented to the emergency department with a 4-day history of severe abdominal pain, nausea, vomiting, abdominal distension, and constipation. She had been diagnosed with Crohn’s disease 2 years earlier and was treated with azathioprine, 5-aminosalicylic acid, and prednisone; she reported no
990
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CID 2014:58 (1 April)
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PHOTO QUIZ
Clinical Infectious Diseases 2014;58(7):990 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@ oup.com. DOI: 10.1093/cid/cit944
Downloaded from http://cid.oxfordjournals.org/ at University of Prince Edward Island on October 30, 2014
Figure 1. Lactophenol cotton blue stain of growth from fine needle aspiration material from the liver lesion (original magnification ×400).
improvement of abdominal symptoms despite treatment for 1 year. Her temperature was 37.1°C, heart rate was 104 bpm, and blood pressure was 103/67 mm Hg. Abdomen was distended, soft, and nontender, with exaggerated bowel sounds and no masses or organomegaly. Abdominal plain radiography revealed bowel distention with multiple air-fluid levels. Blood tests revealed a white blood cell count of 7.07 × 109cells/ L, with 70% neutrophils, 5% lymphocytes, 14.6% eosinophils, and 6% monocytes. The erythrocyte sedimentation rate was 94 mm/ hour. Liver enzymes including total bilirubin and alkaline phosphatase were normal, as was renal function. Magnetic resonance imaging of the abdomen showed 2 long segments of circumferential heterogeneous enhancing soft tissue masses involving the descending colon and descending sigmoid colon with surrounding fat stranding and few nodular peritoneal deposits. There was bowel obstruction and multiple different-size hepatic lesions. Biopsy of the distal descending colon, proximal sigmoid, and rectosigmoid showed focal active colitis with predominant eosinophils and ulceration with no evidence of malignancy. Results of fine needle aspiration of 1 of the liver lesions are shown in Figure 1. What is your diagnosis?
Chronic Abdominal Pain and Intestinal Obstruction in a 24-Year-Old Woman (See pages 1035–6 for the Answer to the Photo Quiz.)
A 24-year-old woman from Saudi Arabia with type I diabetes mellitus presented to the emergency department with a 4-day history of severe abdominal pain, nausea, vomiting, abdominal distension, and constipation. She had been diagnosed with Crohn’s disease 2 years earlier and was treated with azathioprine, 5-aminosalicylic acid, and prednisone; she reported no
990
•
CID 2014:58 (1 April)
•
PHOTO QUIZ
Clinical Infectious Diseases 2014;58(7):990 © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@ oup.com. DOI: 10.1093/cid/cit944
Downloaded from http://cid.oxfordjournals.org/ at University of Prince Edward Island on October 30, 2014
Figure 1. Lactophenol cotton blue stain of growth from fine needle aspiration material from the liver lesion (original magnification ×400).
improvement of abdominal symptoms despite treatment for 1 year. Her temperature was 37.1°C, heart rate was 104 bpm, and blood pressure was 103/67 mm Hg. Abdomen was distended, soft, and nontender, with exaggerated bowel sounds and no masses or organomegaly. Abdominal plain radiography revealed bowel distention with multiple air-fluid levels. Blood tests revealed a white blood cell count of 7.07 × 109cells/ L, with 70% neutrophils, 5% lymphocytes, 14.6% eosinophils, and 6% monocytes. The erythrocyte sedimentation rate was 94 mm/ hour. Liver enzymes including total bilirubin and alkaline phosphatase were normal, as was renal function. Magnetic resonance imaging of the abdomen showed 2 long segments of circumferential heterogeneous enhancing soft tissue masses involving the descending colon and descending sigmoid colon with surrounding fat stranding and few nodular peritoneal deposits. There was bowel obstruction and multiple different-size hepatic lesions. Biopsy of the distal descending colon, proximal sigmoid, and rectosigmoid showed focal active colitis with predominant eosinophils and ulceration with no evidence of malignancy. Results of fine needle aspiration of 1 of the liver lesions are shown in Figure 1. What is your diagnosis?
