2016-09-02 13:37:46 UTC

Image Challenge: What’s Afflicting this Man with Ulcerative Colitis?

Sept. 8, 2016

Gastroenterology image challenge highlights patient with ulcerative colitis presenting with painful anterior chest wall mass, compatible with abscess on CT and possible osteomyelitis.

Gastroenterology image challenge features a 49-year-old man with history of ulcerative colitis and chronic anemia presented to the emergency department with complaints of pain and swelling on his chest, rapidly increasing in size for two-to-three days. He also complained of painful swelling of the right fourth finger and a small painful lesion on his right ankle. He denied subjective fever, chills, nausea or emesis. The patient reported having two-to-three loose brown bowel movements daily without blood, mucus or tenesmus, which was unchanged from his baseline. The patient had been admitted 13 months prior with a diagnosis of left ankle cellulitis and an active ulcerative colitis flare requiring steroids. Last colonoscopy was five years prior during flare and displayed active chronic colitis without evidence of dysplasia. The patient’s active medications included oral mesalamine.

Physical examination revealed a thin man in no acute distress. A tender 4×3-cm mass was located on the central anterior chest wall, overlying his sternum (Figure A). The mass was soft, but not fluctuant. There was no purulence, drainage, warmth or erythema noted. The patient’s right fourth finger was tender, edematous erythematous and warm to touch. A 1×1-cm region of tender erythema was present on right lateral malleolus. No drainage or fluctuance was noted.

Laboratory tests revealed a white blood cell count of 11.9 (64.2 percent neutrophils, 21.7 percent lymphocytes, 12.1 percent monocytes), hemoglobin/hematocrit of 7.1/22.7 percent, platelets of 786, erythrocyte sedimentation rate of 84, C-reactive protein of 14.3, albumin of 2.2, iron of lessthan 10, total iron binding capacity of 227, and ferritin of 60.2. Blood cultures taken on arrival were negative ×2. CT of the chest revealed a 2.6×4.2×2.1-cm hypodensity in the anterior chest wall with minimal peripheral enhancement, compatible with an abscess, and faint cortical irregularities in the adjacent sternum concerning for osteomyelitis (Figure B). Needle aspiration did not yield fluid of any kind.

What is the most likely etiology of the chest wall lesion? What is the appropriate treatment?

Find out on the Gastroenterology website or download the AGA 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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