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Case 6-2013: a 54-Year-Old Man with Recurrent Diarrhea

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Case 6-2013: a 54-Year-Old Man with Recurrent Diarrhea T h e new england journal o f medicine case records of the massachusetts general hospital Founded by Richard C. Cabot Nancy Lee Harris, m.d., Editor Eric S. Rosenberg, m.d., Editor Jo-Anne O. Shepard, m.d., Associate Editor Alice M. Cort, m.d., Associate Editor Sally H. Ebeling, Assistant Editor Emily K. McDonald, Assistant Editor Case 6-2013: A 54-Year-Old Man with Recurrent Diarrhea Leigh H. Simmons, M.D., Alexander R. Guimaraes, M.D., and Lawrence R. Zukerberg, M.D. PRESENTATION OF CASE Dr. Michael T. Forrester (Medicine): A 54-year-old man was admitted to this hospital From the Departments of Medicine because of diarrhea, vomiting, and weight loss. (L.H.S.), Radiology (A.R.G.), and Pathol- ogy (L.R.Z.), Massachusetts General Hos- The patient was well until approximately 2.5 years before admission, when pital; and the Departments of Medicine abdominal cramping and nonbloody diarrhea developed 1 day after he flew from (L.H.S.), Radiology (A.R.G.), and Pathol- the Northeast to Colorado for a skiing trip; the symptoms persisted for the dura- ogy (L.R.Z.), Harvard Medical School — both in Boston. tion of his 4-day vacation. Four days after returning home, he went to the emer- gency department of another hospital because of persistent symptoms, where he was N Engl J Med 2013;368:757-65. DOI: 10.1056/NEJMcpc1208149 told he had a stomach virus. The next day, he saw his primary care provider, and Copyright © 2013 Massachusetts Medical Society. ciprofloxacin was administered, without benefit. One month later, he saw a gas- troenterologist. Routine laboratory studies were normal. A stool specimen showed many leukocytes and no ova or parasites; a stool assay for Clostridium difficile and a stool culture were negative. A course of metronidazole was administered for 10 days, and the symptoms nearly resolved. Two years before this admission, esophagogastroduodenoscopy reportedly re- vealed an inlet patch (i.e., an area of ectopic gastric mucosa) involving the circum- ference of the cervical esophagus and extending at least 4 cm in length, multiple erosions of the gastric antrum, antral gastritis, superficial ulcerations in the duo- denum, and a prominent mucosal fold in the gastric side of the gastroesophageal junction. A colonoscopy showed several small polyps. Pathological examination of the biopsy specimens of the proximal portion of the esophagus reportedly showed squamous mucosa and gastric-type mucosa, with intestinal metaplasia that was thought to be consistent with Barrett’s esophagus. Pathological examination of a biopsy specimen of a polyp in the transverse colon revealed adenomatous changes and low-grade dysplasia; a hyperplastic rectal polyp and normal fragments of duo- denal mucosa were also seen. Testing for Helicobacter pylori and giardia was nega- tive. Proton-pump inhibitors were prescribed. Nine months later, 1 day after another flight to Colorado, the patient again awoke with abdominal cramps and watery diarrhea (up to one episode per hour); 3 days later, nausea and vomiting developed. Examination of a stool specimen at that time revealed Blastocystis hominis, and the symptoms again resolved after treat- ment with metronidazole. n engl j med 368;8 nejm.org february 21, 2013 757 The New England Journal of Medicine Downloaded from nejm.org by NASER DARIANI on September 24, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. T h e new england journal o f medicine Four months before admission, the patient industry, and was monogamous with his girl- traveled to the Middle East. While traveling, he friend. He drank alcohol in moderation, had stayed in hotels and drank only bottled water. smoked as a young adult, and did not use illicit The day after arrival, abdominal cramping devel- drugs. He had had no exposures to sick persons oped, with watery, nonbloody diarrhea occurring or animals and had no history of ingestion of every 1 to 2 hours during the day and occasion- unpasteurized milk products or raw meats. He had ally awakening him at night. His discomfort traveled annually to the Caribbean for 14 years, increased with eating. On the sixth day, nausea most recently 8 years before admission. His fa- and nonbloody, nonbilious vomiting (two to three ther was 82 years of age and had dementia, his episodes daily) occurred, in association with in- mother was deceased and had a history of Par- creased diarrhea and without fevers or diaphore- kinson’s disease and heart disease, and an uncle sis. None of his 15 travel companions had symp- reportedly had stomach cancer. toms. Twelve days later, the patient returned On examination, the blood pressure was home. His symptoms persisted, and 3 weeks 133/94 mm Hg and the pulse 120 beats per min- after their onset, he went to a second hospital ute; the temperature, respirations, and oxygen for evaluation; intravenous fluids and metroni- saturation while the patient was breathing ambi- dazole were administered, but the symptoms ent air were normal, as was the remainder of the worsened. Examination of the stool for pathogens examination. The platelet count, activated partial- and screening for H. pylori were negative. During thromboplastin time, and serum levels of calci- the next 3 months, anorexia developed, and the um, phosphorus, magnesium, and prealbumin patient lost 15.9 kg. Approximately 2 weeks before were normal, as were the results of liver-function admission, his physician prescribed trimethoprim– tests; other test results are shown in Table 1. An sulfamethoxazole, with partial improvement of electrocardiogram was normal. Normal saline diarrhea. was infused. The patient was admitted to this Eight days before admission, the patient was hospital. seen in the infectious-disease clinic of this hos- Computed tomography (CT) of the abdomen pital. On examination, the blood pressure was and pelvis after the oral and intravenous admin- 114/86 mm Hg and the pulse was 88 beats per istration of contrast material showed thickening minute; the remainder of the physical examina- and enhancement of the proximal small-bowel tion was normal. The platelet count, erythrocyte walls, mild dilatation in the small bowel, a large sedimentation rate, red-cell indexes, and serum amount of fluid in the small bowel and colon levels of glucose, urea nitrogen, calcium, vita- with air–fluid levels, an enlarged retroperitoneal min B12, C-reactive protein, cortisol, thyrotro- node (1.3 cm in the short axis), calcific athero- pin, amylase, and lipase were normal, as were sclerosis of the aorta, and a ground-glass nodule the results of liver-function tests. Testing for IgA (0.7 cm in diameter) in the lower lobe of the antibodies to gliadin, endomysial antigen, and right lung. Omeprazole, prochlorperazine, and tissue transglutaminase was negative; other test ondansetron hydrochloride were administered, results are shown in Table 1. Stool specimens and additional crystalloid solution was infused showed no enteric pathogens, ova, or parasites, intravenously. Urinalysis revealed 1+ ketones and and testing for C. difficile toxin was negative. albumin and was otherwise normal. During the During the ensuing week, the patient’s symptoms next 2 days, levels of erythropoietin and folate worsened and included diarrhea (occurring hour- were found to be normal, and testing for human ly throughout the day), constant nausea, vomiting immunodeficiency virus (HIV) antibodies was within 3 minutes after oral intake, and weak- negative; other test results are shown in Table 1. ness, with orthostatic lightheadedness. He came Stool studies were again unrevealing. to the emergency department of this hospital. On the fourth day, the level of potassium in The patient reported no fever, chills, sweats, the stool was 21.7 mmol per liter (serum level, flushing, or headache. His only medication was 3.4 mmol per liter) and stool fat was 37% (refer- omeprazole, 20 mg daily, which he took for ence range, 0 to 19). Esophagogastroduodenos- symptoms of gastroesophageal reflux. He had no copy revealed erosive or exudative circumferen- known allergies. He was of Ashkenazi (Eastern tial lesions (grade III esophagitis, according to European) Jewish ancestry, worked in a service the modified Savary–Miller classification, which 758 n engl j med 368;8 nejm.org february 21, 2013 The New England Journal of Medicine Downloaded from nejm.org by NASER DARIANI on September 24, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. case records of the massachusetts general hospital Table 1. Laboratory Data.* 8 Days before, 2nd and 3rd Variable Reference Range, Adults† Outpatient Clinic On Admission Hospital Days Blood Hematocrit (%) 41.0–53.0 (men) 54.6 54 in emergency department; 44.9 49.6 after administration of intra venous fluids Hemoglobin (g/dl) 13.5–17.5 (men) 19.1 17.9 16.0 White-cell count (per mm3) 4500–11,000 9800 16,600 17,300 Differential count (%) Neutrophils 40–70 71 76 79 Lymphocytes 22–44 16 17 12 Monocytes 4–11 10 5 7 Eosinophils 0–8 2 1 1 Basophils 0–3 1 1 1 Reticulocytes (%) 0.5–2.5 1.6 Prothrombin time (sec) 11.0–13.7 14.2 International normalized ratio for 1.2 prothrombin time Sodium (mmol/liter) 135–145 139 133 137 Potassium (mmol/liter) 3.4–4.8 3.3 3.6 3.5 Chloride (mmol/liter) 100–108 91 92 98 Carbon dioxide (mmol/liter) 23.0–31.9 26.2 30.3 29.8 Anion gap (mmol/liter) 3–15 22 11 9 Creatinine (mg/dl) 0.60–1.50 1.64 1.04 1.04 Estimated glomerular filtration rate ≥60 47 >60 >60 (ml/min/1.73 m2) Glucose (mg/dl) 70–110 87 120 122 Protein (g/dl) Total 6.0–8.3 8.4 6.9 Albumin 3.3–5.0 5.2 4.2 Globulin 2.6–4.1 3.2 2.7 Osmolality (mOsm/kg of water) 280–296 283 Immunoglobulins (mg/dl) IgA 69–309 140 IgG 614–1295 425 IgM 53–334 49 Urine Sodium (mmol/liter) Not defined 102 Creatinine (mg/ml) Not defined 1.91 Stool Sodium (mmol/liter) Not defined 96 Chloride (mmol/liter) Not defined 67 Osmolality (mOsm/kg of water) Not defined 306 * To convert the values for glucose to millimoles per liter, multiply by 0.05551.
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