Michell Lopez, MD, Eric Then, MD, Ali Chaudhri, MD, Andrea Culliford, MD, FACG, Vinaya Gaduputi, MD, FACG; St. Barnabas Hospital, Bronx, NY
Introduction: Cryoglobulinemic vasculitis is a small-to-medium vessel vasculitis caused by cryoglobulin-containing immune complexes mainly involving the skin, the joints, the peripheral nerve system, and the kidneys. Gastrointestinal involvement can be seen in approximately 5% of the cases, manifested as ischemic bowel disease, gastrointestinal hemorrhage, peritonitis, and acute lesions of the pancreas and gallbladder. We present the case of a 66-year-old female patient who developed ischemic colitis as a consequence of cryoglobulinemic vasculitis.
Methods: The patient is a 66-year-old female with a medical history of hypertension, cerebrovascular accident, congestive heart failure, mitral valve regurgitation, and cryoglobulinemic vasculitis who was taken to the emergency department for confusion. She was initially admitted to the intensive care unit under the impression of acute encephalopathy secondary to hypoglycemia, and heart failure exacerbation. Her course was complicated with hematochezia and hematemesis, for which the gastroenterology team was consulted. On physical exam the patient was afebrile, hemodynamically stable, the abdomen was soft and diffusely tender. She also had ischemia of her digits (Figure 1.) The rectal exam revealed blood in stools. Computed tomography angiography (CTA) of the abdomen revealed moderate to high-grade stenosis of the proximal celiac axis with post stenotic dilation. She then underwent a colonoscopy that revealed patchy erythematous mucosa with ulcerations/denudation and pseudomembrane formation in the examined portion of the colon (Figure 2). The endoscopic picture was consistent with underlying ischemic pathology. Biopsies were taken and pathology showed surface epithelial necrosis in the background of acute inflammation and vascular thrombosis, consistent with ischemic colitis (Figure 3). The clinical course was posteriorly complicated with acute respiratory failure secondary to severe mitral regurgitation for which was transferred to another facility for mitral valve repair and was lost to follow up. Discussion: Cryoglobulinemic vasculitis usually runs a slow course, but flares can present with life-threatening manifestations, of which gastrointestinal involvement is one of the most severe. Prompt diagnosis and adequate immunosuppressive therapy, revascularization, or surgical treatment in the appropriate settings are crucial for a successful recovery and prevention of irreversible damage or death.
Figure 1. Physical exam showing ischemic changes of the patients digits.
Figure 2. Colonoscopy revealing patchy erythematous mucosa with ulcerations and pseudomembrane formation.
Figure 3. Surface epithelial necrosis in the background of acute inflammation and vascular thrombosis, consistent with ischemic colitis
Disclosures: Michell Lopez indicated no relevant financial relationships. Eric Then indicated no relevant financial relationships. Ali Chaudhri indicated no relevant financial relationships. Andrea Culliford indicated no relevant financial relationships. Vinaya Gaduputi indicated no relevant financial relationships.