A 30-year-old Caucasian male with a history of ileocolonic Crohn's disease diagnosed 15 years earlier presented to our hospital complaining chiefly of persistent abdominal pain with bloody diarrhea and bilious emesis. His Crohn's had previously been managed with intermittent prednisone tapers at the time of diagnosis in the distant past, as well as a prior colonoscopy in the interim; however, these results were unobtainable. Overall, it appeared that his Crohn's disease had been in remission for approximately 15 years prior to this presentation. As part of his outpatient management for abdominal pain and bloody diarrhea, he had recently started treatment with adalimumab approximately 4 weeks prior to presentation, currently taking 40 mg every other week subcutaneously. He had moderate-to-severe diffuse abdominal pain with no alleviating or exacerbating factors and his bowel movements were frequent (approx. 3-4 per day), loose, and maroon in color.
Physical examination revealed a young male in no acute distress, with moderate abdominal pain on palpation, but otherwise unremarkable. His laboratory studies were significant for a hemoglobin level of 12.6 g/dL, a mean corpuscular volume of 70.6 fL, and a white blood cell count of 5.5x109/L. His erythrocyte sedimentation rate and C-reactive protein were elevated at 86 mm/h and 88.87 mg/L, respectively. Outpatient tuberculosis testing was negative, and HIV was non-reactive. EBV polymerase chain reaction and heterophile antibody were negative.
In the outpatient setting, he had received a prior computed tomography (CT) scan, which showed significant worsening of the bowel wall thickening and inflammatory process involving the cecum and terminal ileum. Given his worsening clinical picture, a repeat CT scan was obtained on admission for interval comparison and to rule out abscess or alternate etiologies of his pain. CT imaging of the abdomen and pelvis with contrast on admission showed a greater than 20 cm segment of bowel wall thickening and dilatation involving the terminal ileum and cecum (Fig. 1). Given the concern about an underlying Crohn's flare, and since he was failing outpatient management with adalimumab, he was initially started on a trial of IV hydrocortisone 100 mg t.i.d. and infliximab 5 mg/kg, but his clinical picture continued to deteriorate, prompting a colonoscopy. This revealed several polypoid masses with stigmata of recent bleeding extending for over 20 cm from the hepatic flexure to the cecum with partial obstruction of the lumen (Fig. 2). Given the altered anatomy from the circumferential, contiguous mass lesions, the terminal ileum was not found and no normal colonic mucosa was present on the right side of the colon. The typical endoscopic stigmata of Crohn's disease were not present and multiple biopsies from the right-sided colon lesions were taken. Pathology from the biopsies returned with a final diagnosis of classic t(8;14) Burkitt's lymphoma and he went on to be treated with combination chemotherapy resulting in clinical remission.