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Presented by Dr. Pedram Argani and prepared by Dr. Harsimar Kaur
This is a 14 year old male with a history of cancer who now has diarrhea.
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1. Question
This is a 14 year old male with a history of cancer who now has diarrhea.
Correct
Answer: A
Histologic Description: The bowel wall is markedly thickened with prominent submucosal edema. There are patchy areas of mucosal necrosis over which there is a luminal pseudomembrane composed of fibrin, mucus, neutrophils, and dead intestinal epithelial cells. There is fibrin in the lamina propria. Elsewhere, the bowel is edematous but there is no evidence of crypt distortion, granuloma or thickened basement membranes. These are the typical features of pseudomembranous colitis.
Differential Diagnosis: Ulcerative colitis and Crohns disease would be associated with chronic inflammatory changes, including crypt distortion, basal plasmacytosis, and in the case of Crohns disease noncaseating granulomas. None of these are present in the current case. Collagenous colitis would be associated with increased subepithelial collagen, and an uncomplicated case would not show the acute inflammatory changes seen here. The differential diagnosis for the pseudomembranous colitis pattern includes C. difficile colitis, which is associated a prior history of antibiotic therapy as was present in the current case. In older patients, ischemia can give a similar pattern, while E.coli 0157:H7 acquired through food poisoning can also give this pattern. In severe cases such as this, one can see full thickness mucosal necrosis resulting in a toxic megacolon that requires colectomy.
Incorrect
Answer: A
Histologic Description: The bowel wall is markedly thickened with prominent submucosal edema. There are patchy areas of mucosal necrosis over which there is a luminal pseudomembrane composed of fibrin, mucus, neutrophils, and dead intestinal epithelial cells. There is fibrin in the lamina propria. Elsewhere, the bowel is edematous but there is no evidence of crypt distortion, granuloma or thickened basement membranes. These are the typical features of pseudomembranous colitis.
Differential Diagnosis: Ulcerative colitis and Crohns disease would be associated with chronic inflammatory changes, including crypt distortion, basal plasmacytosis, and in the case of Crohns disease noncaseating granulomas. None of these are present in the current case. Collagenous colitis would be associated with increased subepithelial collagen, and an uncomplicated case would not show the acute inflammatory changes seen here. The differential diagnosis for the pseudomembranous colitis pattern includes C. difficile colitis, which is associated a prior history of antibiotic therapy as was present in the current case. In older patients, ischemia can give a similar pattern, while E.coli 0157:H7 acquired through food poisoning can also give this pattern. In severe cases such as this, one can see full thickness mucosal necrosis resulting in a toxic megacolon that requires colectomy.
