A Unique Cause of Persistent Diarrhea - Gastroenterology

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Answer to: Image 3 (page 1291): Protein-Losing Enteropathy Caused by. Sarcoidosis in the Gastrointestinal Tract. Noncaseous epithelial cell granuloma was ...
CLINICAL CHALLENGES AND IMAGES IN GI A Unique Cause of Persistent Diarrhea Tomoya Iida, Kentaro Yamashita, and Hiroshi Nakase Department of Gastroenterology and Hepatology, Sapporo Medical University, School of Medicine, Sapporo, Japan

Question: A 60-year-old man with a 5-year history of intermittent diarrhea had been experiencing approximately 5 episodes a day when he visited our hospital. The diarrhea was watery, and he had no abdominal pain, but slight edema was noted in his lower legs. Blood test results revealed decreased albumin level of 1.5 g/dL, normal C-reactive protein level, and increased serum-soluble interleukin-2 receptor (sIL-2R) level of 1443 U/mL. Upper gastrointestinal endoscopy revealed many small white nodules throughout the esophagus (Figure A), and the duodenal mucous membrane was edematous and rough (Figure B). On lower gastrointestinal endoscopy, small white erosions were found throughout the colon (Figure C, narrow-band imaging), and the rectal mucous membrane was edematous (Figure D), although no abnormality was found in the terminal ileum. What is the diagnosis? Look on page 1292 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Conflicts of interest The authors disclose no conflicts. © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.11.051

Gastroenterology 2017;152:1291–1292

CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 3 (page 1291): Protein-Losing Enteropathy Caused by Sarcoidosis in the Gastrointestinal Tract

Noncaseous epithelial cell granuloma was detected in the biopsy specimens from both the upper and lower gastrointestinal tracts (Figure E, F). In addition, contrast-enhanced computed tomography revealed swollen mediastinal and hilar lymph nodes (Figure G, H, arrow), and granuloma was observed in the erythrogenic eruption on the forehead (Figure I, J). Although the angiotensin-converting enzyme level was normal, the sIL-2R level was high and the tuberculin test was negative, leading to the diagnosis of sarcoidosis. In addition, the a1-antitrypsin clearance test revealed protein leakage, which suggested protein-losing enteropathy comorbid with intestinal sarcoidosis. The albumin level gradually increased after prednisolone 30 mg/d was started. A previous study reported that 1.6% of sarcoidosis cases had associated intestinal lesions. Only a few reports have stated that esophageal lesions are rare. However, there are also few reports of sarcoidosis with protein leakage, with only 3 cases reported in the literature.1–3 Because edema and small white nodules have been reported in other cases, they are considered important indicators of intestinal lesions of sarcoidosis.

References 1. 2. 3.

 OS, Brkic  S, Bojic  P, et al. Sarcoidosis and protein losing enteropathy. Gastroenterology 1980;78:119–125. Popovic Lindgren A, Engström CP, Nilsson O, et al. Protein-losing enteropathy in an unusual form of sarcoidosis. Eur J Gastroenterol Hepatol 1995;7:1005–1007. Boyum RD, Yeung KJ, Kaplan KJ, et al. Pediatric gastrointestinal sarcoidosis presenting with protein-losing enteropathy. J Pediatr Gastroenterol Nutr 2007;44:152–156.

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