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Defecation of a “colon cast” as a rare presentation of acute graft-versus-host disease

Al Ashgar H, Peedikayil M, Chaudhri N, Al-Ghamdi A - Ann Saudi Med (2009 May-Jun)

Bottom Line: On the fourth day of admission, the patient passed per rectum a 27-cm long pinkish colored fleshy material recognized as a "colon cast".Sigmoidoscopy showed a congested and erythematous rectum with the remaining portion of the "colon cast" attached to the proximal part of the sigmoid colon.The patient was treated with methylprednisolone, cyclosporin and mycophenolate mofetil, with a partial response (diarrhea and abdominal pain improved), but then he developed multiple other medical complications and died after 3 months.

Affiliation: Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.

ABSTRACT

Diffuse involvement of the gastrointestinal tract by graft versus host disease (GVHD) is a common complication of allogeneic hematopoietic stem cell transplant (HSCT). Gastrointestinal GVHD usually presents 3 or more weeks after HSCT and is characterized by profuse diarrhea, anorexia, nausea, vomiting, abdominal pain and gastrointestinal bleeding. We report a case of a 23-year-old male who had undergone allogeneic HSCT and presented with bloody diarrhea on the 90th day post-HSCT. On the fourth day of admission, the patient passed per rectum a 27-cm long pinkish colored fleshy material recognized as a "colon cast". Sigmoidoscopy showed a congested and erythematous rectum with the remaining portion of the "colon cast" attached to the proximal part of the sigmoid colon. A biopsy from the rectal wall was suggestive of grade IV GVHD. The patient was treated with methylprednisolone, cyclosporin and mycophenolate mofetil, with a partial response (diarrhea and abdominal pain improved), but then he developed multiple other medical complications and died after 3 months.

Histology of the sigmoid colon showing granulation tissue and base ulcers suggesting severe graft versus host disease.
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Figure 0002: Histology of the sigmoid colon showing granulation tissue and base ulcers suggesting severe graft versus host disease.

Mentions: Laboratory tests on admission were as follows: WBC 7.46×109/L (normal, 3.9-11×109/L), hemoglobin 104 g/L (normal, 110-160 g/L), platelet count 10×109/L (normal, 155-435 109/L), urea 5.3 mmol/L (normal, 2.5-7.5 mmol/L), creatinine 88 micromols/L (normal, 46-96 micromols/L), potassium 3.1 mmol/L (normal, 3.5-5 mmol/L), sodium 138 mmol/L (normal, 135-147 mmol/L), carbon dioxide 19 mmol/L (normal, 22-31 mmol/L), albumin 26 g/L (normal, 32-48 g/L), bilirubin 21 μmol/L (normal, 0-21 μmol/L), lactic acid 0.8 mmol/L (normal, 5-2 mmol/L), ALT 30 U/L (normal, 10-45 U/L), and alkaline phosphatase 223 U/L (normal, 30-125U/L). The histology of the sigmoid colon showed granulation tissue and base ulcers suggestive of grade IV acute GVHD (Figure 2). The histology of the colon cast showed necrotic fibrino-purulent exudate with bacterial overgrowth (Figure 3). There was no evidence of CMV infection in the histology of the sigmoid colon and CMV culture was negative.

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Defecation of a “colon cast” as a rare presentation of acute graft-versus-host disease

Al Ashgar H, Peedikayil M, Chaudhri N, Al-Ghamdi A - Ann Saudi Med (2009 May-Jun)

Histology of the sigmoid colon showing granulation tissue and base ulcers suggesting severe graft versus host disease.
© Copyright Policy
Figure 0002: Histology of the sigmoid colon showing granulation tissue and base ulcers suggesting severe graft versus host disease.
Mentions: Laboratory tests on admission were as follows: WBC 7.46×109/L (normal, 3.9-11×109/L), hemoglobin 104 g/L (normal, 110-160 g/L), platelet count 10×109/L (normal, 155-435 109/L), urea 5.3 mmol/L (normal, 2.5-7.5 mmol/L), creatinine 88 micromols/L (normal, 46-96 micromols/L), potassium 3.1 mmol/L (normal, 3.5-5 mmol/L), sodium 138 mmol/L (normal, 135-147 mmol/L), carbon dioxide 19 mmol/L (normal, 22-31 mmol/L), albumin 26 g/L (normal, 32-48 g/L), bilirubin 21 μmol/L (normal, 0-21 μmol/L), lactic acid 0.8 mmol/L (normal, 5-2 mmol/L), ALT 30 U/L (normal, 10-45 U/L), and alkaline phosphatase 223 U/L (normal, 30-125U/L). The histology of the sigmoid colon showed granulation tissue and base ulcers suggestive of grade IV acute GVHD (Figure 2). The histology of the colon cast showed necrotic fibrino-purulent exudate with bacterial overgrowth (Figure 3). There was no evidence of CMV infection in the histology of the sigmoid colon and CMV culture was negative.

Bottom Line: On the fourth day of admission, the patient passed per rectum a 27-cm long pinkish colored fleshy material recognized as a "colon cast".Sigmoidoscopy showed a congested and erythematous rectum with the remaining portion of the "colon cast" attached to the proximal part of the sigmoid colon.The patient was treated with methylprednisolone, cyclosporin and mycophenolate mofetil, with a partial response (diarrhea and abdominal pain improved), but then he developed multiple other medical complications and died after 3 months.

Affiliation: Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.

ABSTRACT

Background: Diffuse involvement of the gastrointestinal tract by graft versus host disease (GVHD) is a common complication of allogeneic hematopoietic stem cell transplant (HSCT). Gastrointestinal GVHD usually presents 3 or more weeks after HSCT and is characterized by profuse diarrhea, anorexia, nausea, vomiting, abdominal pain and gastrointestinal bleeding. We report a case of a 23-year-old male who had undergone allogeneic HSCT and presented with bloody diarrhea on the 90th day post-HSCT. On the fourth day of admission, the patient passed per rectum a 27-cm long pinkish colored fleshy material recognized as a "colon cast". Sigmoidoscopy showed a congested and erythematous rectum with the remaining portion of the "colon cast" attached to the proximal part of the sigmoid colon. A biopsy from the rectal wall was suggestive of grade IV GVHD. The patient was treated with methylprednisolone, cyclosporin and mycophenolate mofetil, with a partial response (diarrhea and abdominal pain improved), but then he developed multiple other medical complications and died after 3 months.

View Similar Images In: Results  - Collection
View Article: Pubmed Central -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=2813650&rFormat=json&query=null&req=5