2017-07-13 13:45:46 UTC

Febrile Attacks With a Refractory Colonic Lesion

July 12, 2017

Gastroenterology image challenge involves a 68-year old woman with refractory inflammatory bowel disease and history of pulmonary tuberculosis.

Gastroenterology Clinical Image Challenge: In April 2015, a 68-year-old woman with refractory inflammatory bowel disease was referred to our hospital for further examination. She had a history of pulmonary tuberculosis. Her symptoms of self-remitting fever, diarrhea and abdominal pain initially occurred in 2005. Colonoscopy revealed multiple erosions with loss of mucosal vascularity throughout the colorectum. Although she was administered 4 g of mesalazine per day, her symptoms recurred. In 2014, ileocolonoscopy showed multiple ulcers and erosions in the terminal ileum and the ascending colon. She was administered 40 mg of oral prednisolone per day. Although her symptoms subsided, ileocolonic involvement remained active under ileocolonoscopy. In February 2015, she had a febrile attack with body temperature over 38°C and abdominal pain that spontaneously subsided within two days. In March, her symptoms repeated and laboratory data showed severe inflammation (white blood cell [WBC] count, 24,350/μL; C-reactive protein [CRP], 15.2 mg/dL) that lead to her referral to our hospital.

On admission, her symptoms subsided and laboratory data only showed mild inflammatory reaction (WBC, 10,140/μL; CRP, 0.18 mg/dL). Immunologic tests revealed negative antinuclear antibody and positive QuantiFERON test. Ileocolonoscopy disclosed erythematous mucosa with multiple ulcers and erosions in the ascending colon (Figure A) and in the terminal ileum (Figure B). Other small intestinal involvement was not found under capsule endoscopy or balloon-assisted endoscopy.

What is the diagnosis?

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