Inayat Gill, DO1, Aciel A. Shaheen, MD1, Ahmed I. Edhi, MD1, Mitual B. Amin, MD2, Ketan Rana, MD1, Mitchell S. Cappell, MD, PhD1; 1William Beaumont Hospital, Royal Oak, MI; 2William Beaumont Hospital, Royak Oak, MI
Introduction: Collagenous colitis (CC) classically produces watery diarrhea attributed to a thick collagen layer blocking colonic reabsorption of water/electrolytes. Four cases of CC have been associated with protein-losing enteropathy (PLE), but CC by itself should not produce PLE because the colon does not reabsorb amino acids. About ten cases of collagenous duodenitis with CC have been reported, but none had (severe) PLE. A novel case is reported of severe PLE associated with collagenous duodenitis and CC. This association is biologically reasonable because duodenum/small bowel is responsible for amino acid absorption, which could be blocked by collagenous duodenitis.
Methods: A 65-year-old female with a heavy smoking history and no prior renal insufficiency, presented with 5 watery stools/day and 14 kg involuntary weight loss for 3 months. Physical exam revealed dry mucous membranes and non-tender, non-distended abdomen. Laboratory tests revealed serum creatinine=3.61 mg/dL (normal: 0.6-1.3 mg/dL). Stool tests for Clostridiumdifficile toxins and ova and parasites were negative. Stool culture for bacterial pathogens was sterile. Abdomino-pelvic CT was within normal limits. Colonoscopy with biopsy of endoscopically normal colonic mucosa revealed CC (Fig-1). She was treated with aggressive IV hydration and budesonide with reversal of renal failure. She was readmitted 1 month later for refractory nausea and vomiting. Physical exam revealed severe anasarca, with albumin=2.3 g/dl (normal: 3.5-4.9 g/dL), normal liver and cardiac functions and no proteinuria. Stool alpha-1-antitrypsin was 369 mg/dl (normal: < 54 mg/dl), diagnostic of PLE. EGD revealed endoscopically normal duodenum. Histopathology of endoscopic biopsies showed severe collagenous duodenitis (Fig-2,3). She was diagnosed with severe PLE, from collagenous duodenitis/CC and malnutrition, treated with azathioprine and budesonide. She returned 2 months later with dyspnea, worsening diarrhea, severe hypoalbuminemia, and hypogammaglobulinemia. She tested positive for COVID-19. She was discharged 11 days later without dyspnea and TPN was initiated. Discussion: This case demonstrates that simultaneous presentation of collagenous duodenitis/CC can result in PLE due to the thick collagen layer preventing absorption of amino acids in small bowel and water/electrolytes in colon. Immunosuppression from hypoalbuminemia, hypogammaglobulinemia, and malnutrition from PLE rendered this patient susceptible to severe COVID-19 infection.
High power photomicrograph of hematoxylin and eosin stained section of random colonic biopsy showing thickened subepithelial collagen (pink) band (>10 micrometer diagnostic of collagenous colitis).
Medium power photomicrograph of hematoxylin and eosin stained section of random biopsy of the duodenum showing thickened subepithelial collagen (pink) band (>10 micrometer diagnostic of collagenous duodenitis).
Medium power photomicrograph of Masson Trichrome stained section of random biopsy of the duodenum involving entire thickness of lamina propria, that highlights collagen in blue.
Disclosures: Inayat Gill indicated no relevant financial relationships. Aciel Shaheen indicated no relevant financial relationships. Ahmed Edhi indicated no relevant financial relationships. Mitual Amin indicated no relevant financial relationships. Ketan Rana indicated no relevant financial relationships. Mitchell Cappell indicated no relevant financial relationships.