2017-06-02 17:00:46 UTC

Blood and Bone Loser

June 14, 2017

This week’s Gastroenterology image challenge covers the case of a 45-year-old man with a 22-year history of Crohn’s disease presented with mild hypocalcemia and severe hypophosphatemia.

Gastroenterology Clinical Image Challenge: A 45-year-old man with a 22-year history of Crohn’s disease was admitted for muscular weakness, and bilateral groin and shoulder pain. On examination the patient presented with waddling walk, proximal muscular weakness and a positive Gower’s sign. Laboratory tests showed anemia with a hemoglobin concentration of 8.2 g/dL. He presented with mild hypocalcemia and severe hypophosphatemia (0.46 mmol/L; ref. range: 0.8–1.45 mmol/L) with increased urinary excretion of phosphate (fractional excretion of phosphate, 46%). His 25-hydroxy-vitamin D and parathyroid hormone serum concentrations were both normal. The patient tested positive for HLA-B27. At the time of presentation, the patient was treated with 30 mg methylprednisolone, 150 mg azathioprine and 1.5 g mesalazine in addition to supplementation of 1 g of calcium and 800 IE vitamin D3 per day. Infliximab had been switched to adalimumab 1 year before presentation.

Recurrent anastomotic stenosis and anastomotic ulcers after ileocecal resection for stenosing and fistulizing disease 1 year after initial presentation required repeated resections of the anastomosis. Despite intravenous iron therapy with iron sucrose, the patient required repeated transfusions before ferric carboxymaltose and recombinant human erythropoietin were commenced owing to ongoing blood loss from anastomotic ulcers. A total of 27 g ferric carboxymaltose had been given over a period of 3 years before presentation.

Magnetic resonance imaging (MRI) showed marked hyperintensities of both femoral necks on T1-weighted imaging using a turbo inversion recovery magnitude sequence. Within these hyperintensities marked horizontal hypointensities extending halfway across the femoral neck were present (Figure A). These abnormalities were undetectable on plain film radiographs, where no fracture lines were present (Figure B).

What is this patient’s diagnosis and what caused this unusual clinical presentation?

To find out the diagnosis, read the full case in Gastroenterology or download our Clinical Image Challenge app through AGA App Central, which features new cases each week. Sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play

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