University of Puerto Rico School of Medicine San Juan, Puerto Rico
Karelys Burgos Irizarry, MD1, Jorge J. Cruz, MD, MSc2, Irene I. Villamil, MD2, Pablo Acosta Garayua, MD1; 1University of Puerto Rico School of Medicine, San Juan, Puerto Rico; 2University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
Introduction: Common Variable Immunodeficiency (CVID) is the most frequent symptomatic primary immunodeficiency in adults characterized by impaired antibody production, decreased levels of serum immunoglobulins and bigger susceptibility to infection. The foremost gastrointestinal symptom encountered is acute and/or chronic diarrhea, which occurs in between 21% and 57% of patients. Manifestations of gut disease descent into 3 main groups: inflammation or autoimmunity, infection and malignancies. Inflammation may present like Crohn’s disease with the presence of granulomas, crypt abscesses, lymphoid aggregates, and exudates. In terms of infection, the most common pathogens are Giardia lamblia, Salmonella species, Campylobacter jejuni, and Cytomegalovirus (CMV).
Methods: We present the case of a 39-year-old male with history of CVID and CVID associated colitis under treatment with immune globulin infusion and vedolizumab, who was admitted due to due to one week history of bloody diarrhea, fever, weakness, and general malaise. Patient reported 6-month history of multiple hospitalizations, skin infections, electrolyte disturbances, watery diarrhea, anemia and weight loss. Laboratories upon admission showed severe leukopenia and symptomatic anemia that required multiple blood transfusions. Esophagogastroduodenoscopy (EGD) showed diffuse cobblestoning mucosa and the histopathology of the stomach revealed chronic abundant active Helicobacter pylori antral gastritis with mild complete intestinal metaplasia. (Figure 1) Colonoscopy upon admission showed active colitis with mucosal ulceration in the rectosigmoid area and immunostaining was negative for CMV. (Figure 2) Colonoscopy six months previous to this episode showed large continuous transmural ulcerations from the rectum throughout sigmoid, with exudates, loss of regular pattern and friability, changes suggestive of Crohn’s colitis. Multiple stool cultures during hospitalization were negative for Shigella, Yersinia and Salmonella, but positive for Campylobacter jejuni. Stool ova and parasites and trichromatic stain were also negative. Discussion: This case is specific because a patient with CVID presented with acute on chronic diarrhea due to Campylobacter infection mimicking changes of active inflammatory disease. This report contributes to a better understanding of atypical presentations of superimposed infectious colitis in immunocompromised patients. It is important to consider infection before pondering in treatment failure or exacerbation.
Figure 1. Antral mucosa with acute inflammatory infiltrate with intestinal metaplasia
Figure 2. Rectosigmoid colon with mucosal ulceration
Disclosures: Karelys Burgos Irizarry indicated no relevant financial relationships. Jorge Cruz indicated no relevant financial relationships. Irene Villamil indicated no relevant financial relationships. Pablo Acosta Garayua indicated no relevant financial relationships.