case presentation · serial imaging date imaging indication findings ... •destruction of 2ndleft...
TRANSCRIPT
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Case Presentation
IBD Interest Group 8 June 2019
Dr Tendai R Machiridza
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Clinical Case
• Mrs EP 50 year old woman married, 4 children• Unemployed • Non-smoker, no alcohol • Brother with CD
• Diagnosed with Crohn’s disease in 1986• Pan-colitis • Normal terminal ileum• No perianal CD
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Complications since diagnosis
• Pyoderma gangrenosum (abdominal wall): 1991
• Scleritis
• Gallstones and renal calculi
• Diabetes mellitus (2001): glucocorticoid induced
• NAFLD
• Osteoarthritis of the lumbar spine
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Intrahepatic PSC
• Diagnosed in 2000– ERCP showed normal extra-hepatic bile ducts– Poor filling of intrahepatic ducts
• Liver biopsy: inconclusive
• Negative autoimmune markers (ANF, ASMA, AMA, LKM)
• Negative Hep A, B and C
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Issues in management
• IBD management: GIT clinic
• PSC treatment and monitoring: liver clinic
0
50
100
150
Dec-
15
Jun-
16
Dec-
16
Jun-
17
Dec-
17
Jun-
18
ALTBIL
0200400600800
10001200
Feb-
…Se
p-…
Apr-
…N
ov…
Jun-
…Ja
n-…
Aug…
Mar
…O
ct-…
May
…
ALP
Ursodiol
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PSC and cancer
• Cancer surveillanceØColorectal cancerØGall bladder cancerØCholangiocarcinoma
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Colonoscopy surveillance for CRCDate Endoscopy Histology
2013 Mild chronic inflammationPseudo-polyps
No dysplasia
2015 Quiescent colitisOccasional pseudo-polyps DC
Mild active colitisNegative for dysplasia
2017 Pseudo-polypsNo active colitis
Chronic active colitisNo dysplasia
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Possible cholangiocarcinoma
• 2015 she developed 20kg weight loss
• MRCP and CT raised concerns about a hilar cholangiocarcinoma
0
100
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300
Mar
-14
Jul-1
4
Nov
-14
Mar
-15
Jul-1
5
Nov
-15
Mar
-16
Jul-1
6
Nov
-16
Mar
-17
Jul-1
7
Nov
-17
Mar
-18
Jul-1
8
Nov
-18
CA19-9
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Work up
• Multidisciplinary teamØ HPBØ GITØ Liver
• ERCP and FNAB: cholangiocarcinoma could not be excluded• It was felt that fluctuating tumour markers were atypical
• However patient not for surgery due to comorbidities• Clinical follow up and palliation
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Serial imaging
Date Imaging Indication Findings
April 2018 US Surveillance Soft tissue GB lesion suggestive of polyp
7 August 2018 MRCP Surveillance No change in GB polypMultiple GB stonesIntrahepatic dilatationNo change in bile ducts appearance
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2017-2019
• Diagnosis of ‘cholangiocarcinoma’ was queried• No clinical progression • Static/fluctuating tumour markers• Inconsistent radiology
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March 2019
• Admitted with significant weight loss• Left sided chest pain• Exertional dyspnoea
• GU symptoms Ø Haematuria and dysuria Ø Urine grew E coli
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Medication
• Azathioprine (200mg/day)• Prednisone (10 - 30mg)• Ursodeoxycholic acid (250mg tds)• Metformin (1g bd)• Insulin (80 units/day)• PPI• Vitamin D• Calcium
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Lab investigations on admission
• ALT 25• AST 15• ALP 1549• GGT 1530• BIL 39• ALB 24
• CA19-9: 129• AFP 0.9
• WCC 10.37• HB 8.2• PLT 769
• CRP 197• Iron studies showed ACD• HIV negative • Calcium 2.08
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CXR in the ward
Sputum: ZN negative for Mycobacterium tuberculosisPCR negative
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CT scan chest and abdomen
Chest• Destruction of 2nd left rib• Associated soft tissue mass
measuring 40x30mm• 3rd and 4th rib also involved
Abdomen• GB calculi• Dilated biliary tree• GB polyp• No metastases
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Differential diagnosis
Likely a non-benign lesion related to her PSCØ Metastatic cholangiocarcinomaØ Metastatic CRCØ Metastatic gallbladder cancer
• Osteosarcoma• Soft-tissue sarcoma
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Diagnosis
• FNAB of soft tissue massØ Mixed inflammatory infiltrateØ Negative ZN stainØ Negative fungal or parasitic stainingØ No cellular atypia or malignancy
Caseating granulomas
Pleural aspiratePCR positive for MTB
Sensitive to RIF
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Further management
• Immunosuppression stopped (AZA, Prednisone)• Full anti TB treatment• One month of treatment:– ALP – 275– GGT – 244– ALT – 20– AST – 27– ALB – 35 – BIL – 222 (stone in CBD)
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Conclusion
• We present a case of complicated CD• PSC• On profound immunosuppression• Presenting with features of a NBL• Diagnosed as TB
The great imitator should always be considered in the differential diagnosis