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Presented by Fred Askin, M.D. and prepared by Kara Judson, M.D.
Case 1: Patient is a 57 year-old woman with a long history of pyelonephritis, treated with multiple antibiotics.
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Question 1 of 1
1. Question
Week 254: Case 1
Patient is a 57 year-old woman with a long history of pyelonephritis, treated with multiple antibiotics. She developed severe bloody diarrhea./images/12306 case 1 1.jpg
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/images/12306 case 1 5.jpgCorrect
Answer: Pseudomembranous colitis
Histology: The characteristic histologic features are the prominent submucosal edema ( which correlates with thickening of the bowel wall that can be seen on CT and sonographic evaluation.) and the patchy destructive mucosal lesion in the form of a plaque characterized by a “mushroom-like” mass of mucus and polymorphonuclear cells attached to the mucosal surface. The surrounding mucosa may be quite normal.
Discussion: Pseudomembranous Colitis is usually caused by toxins produced by Clostridium difficile and the majority of cases have been associated with the use of Lincomycin or Clindomycin. Focal destruction of the superficial portion of the mucosa with pseudomembrane formation is not a specific feature of Pseudomembranous Colitis produced by C. difficile but can also be seen in cases of bowel ischemia. In the latter instance the lesion is more likely to be confluent rather than showing discreet plaques, as in toxic Pseudomembranous Colitis. Further, Ischemic Colitis is typically located in the splenic flexure. Cytomegalovirus Colitis can produce focal ulceration but usually lacks a prominent superficial pseudomembrane. The presence of viral inclusions and, occasionally the use of immunostains will confirm the diagnosis of CMV Colitis. In Amoebic Colitis the mucosa is covered by an exudate but “flask-shaped” ulcers and the presence of trophozooites will lead to the correct diagnosis. Yuan and Associates (Am J Surg Pathol 2003;27:1375-1379) have called attention to the fact that rare cases of Collagenous Colitis may present with a pseudomembrane. An evaluation of the bowel surrounding the plaque-like lesions (in an attempt to find characteristic areas of collagenous colitis) should always be made with this consideration in mind.
Reference(s):
– Rosai J, Rosai and Ackerman’s Surgical Pathology, Ninth Edition,. Mosby Company, New York 2004, pp. 791-795.Incorrect
Answer: Pseudomembranous colitis
Histology: The characteristic histologic features are the prominent submucosal edema ( which correlates with thickening of the bowel wall that can be seen on CT and sonographic evaluation.) and the patchy destructive mucosal lesion in the form of a plaque characterized by a “mushroom-like” mass of mucus and polymorphonuclear cells attached to the mucosal surface. The surrounding mucosa may be quite normal.
Discussion: Pseudomembranous Colitis is usually caused by toxins produced by Clostridium difficile and the majority of cases have been associated with the use of Lincomycin or Clindomycin. Focal destruction of the superficial portion of the mucosa with pseudomembrane formation is not a specific feature of Pseudomembranous Colitis produced by C. difficile but can also be seen in cases of bowel ischemia. In the latter instance the lesion is more likely to be confluent rather than showing discreet plaques, as in toxic Pseudomembranous Colitis. Further, Ischemic Colitis is typically located in the splenic flexure. Cytomegalovirus Colitis can produce focal ulceration but usually lacks a prominent superficial pseudomembrane. The presence of viral inclusions and, occasionally the use of immunostains will confirm the diagnosis of CMV Colitis. In Amoebic Colitis the mucosa is covered by an exudate but “flask-shaped” ulcers and the presence of trophozooites will lead to the correct diagnosis. Yuan and Associates (Am J Surg Pathol 2003;27:1375-1379) have called attention to the fact that rare cases of Collagenous Colitis may present with a pseudomembrane. An evaluation of the bowel surrounding the plaque-like lesions (in an attempt to find characteristic areas of collagenous colitis) should always be made with this consideration in mind.
Reference(s):
– Rosai J, Rosai and Ackerman’s Surgical Pathology, Ninth Edition,. Mosby Company, New York 2004, pp. 791-795.
