A 64-year-old man was diagnosed as having sarcoidosis with
mediastinal and bilateral axillary adenopathy. Bronchoscopy and purified
protein derivative (PPD) skin test were unremarkable. Eleven months later,
three to four bilateral small nodules were seen on a chest computed tomography
(CT) scan. The patient received no treatment because he was asymptomatic.
Three months later, the patient was admitted with a 3-month history
of abdominal discomfort, mainly in the lower abdomen, bloating, diarrhea (four
to five loose watery stools/day), weight loss
(3 – 4 kg), and fatigue, but no night sweats.
Physical examination revealed marginal splenomegaly. Laboratory data showed
mild anemia (hemoglobin 11.3 g/dL), with low ferritin and vitamin
B12 levels. The angiotensin-converting enzyme (ACE) level was
52 U/L and biochemistry was normal. All other markers for gut
malabsorption, including antiendomysial antibodies and immunoelectrophoresis,
were normal. Stool studies including Clostridium
difficile toxin, fecal leukocytes, cultures, ova and parasites, and random
fecal fat were negative.
A colonoscopy revealed edema, granularity, and friability of the
terminal ileac mucosa. Gastroduodenoscopy was unremarkable. Terminal ileum
biopsies revealed thick lymphoplasmacytic and polymorphonuclear cell
infiltration with discrete, noncaseating, epithelioid granulomas containing
Langhans giant cells with central necrosis, suggestive of sarcoidosis.
Esophageal and gastric biopsies were unremarkable, while duodenal biopsies
revealed mild blunting of the villi and lymphoplasmacytic and polymorphonuclear
cell infiltration without granulomas.
Capsule endoscopy of the small bowel revealed scarce superficial
ulcerative lesions in the distal jejunum ([Fig. 1]) and more confluent ulcers in the ileum.
Fig. 1 a Discrete superficial
jejunal ulcer. b Superficial ulcer at the marginal zone
between the jejunum and ileum.
In distal ileum, a small number of larger ulcers (diameter
5 – 6 mm) were present on granular mucosa ([Fig. 2]).
Fig. 2 a, b Edema,
granulosis, and ulceration in the terminal ileum.
Abdominal CT showed mild splenomegaly, three small hypodense lesions
in the spleen, ileac wall thickening, and slight regional lymph node
enlargement.
The patient was prescribed prednisolone 30 mg/day. The
diarrhea settled within a week, and the lesions seen on capsule endoscopy and
colonoscopy regressed within a month of starting the medication. Four months
later the dose of prednisolone was tapered, the intestinal disease remained
inactive, and the ACE level dropped to 19 U/L.
Endoscopy_UCTN_Code_CCL_1AC_2AH
