A 59-year-old African American man with a medical history of pulmonary sarcoidosis presented to the emergency room with a one-month history of abdominal pain and diarrhea. He had been discharged four days prior to this index presentation, after presenting with similar symptoms that was treated as infectious colitis. The abdominal pain was greatest in the periumbilical region and cramping in character. Since the initial onset, the pain changed from intermittent to constant in duration and increased in severity from 4 out of 10 to 10 out of 10. He endorsed associated nausea, unintentional weight loss, bloating, loud bowel sounds, seven to ten loose stools per day, hematochezia, and tenesmus. He also reported a painful genital ulcer and endorsed pain in the distal interphalangeal joints of the fourth digits of his hands that was worse in the morning. He denied other skin changes, fever, chills, vomiting, exposure to ill contacts, new foods, or recent travel. He was a former smoker with a 39-year pack history, drank beer daily, but denied illicit drug use. He denied any personal or family history of inflammatory bowel disease or colon cancer. His colonoscopy three years prior was significant for diverticula and a benign polyp which was removed.
On examination, he was in painful distress and tachycardic with other vitals within normal limits. Abdominal examination revealed hyperactive bowel sounds and diffuse abdominal tenderness with voluntary and involuntary guarding. He had a right inguinal genital ulcer and scattered pustules on his back. Laboratory results revealed hemoglobin, 9.2 g/dL; hematocrit, 31.1%; MCV, 76.4 fL; platelet count, 503 K/cmm; ferritin, 13 L; total iron, 13 L; iron saturation, 4; PT, 16.5 sec; INR, 1.35; vitamin K, <50 mcg; albumin, 3.3 g/dL; C-reactive protein, 81.2 mg/L; ESR, >100 mm/hr; and negative tuberculosis skin test. CT abdomen showed asymmetric wall thickening with subtle adjacent pericolic fat stranding and mesenteric vessel engorgement involving the transverse and proximal sigmoid colon (Figures 1 and 2).
Stool studies were negative for infection. Punch biopsy of the genital ulcer done for H&E and infectious studies revealed fibrosis and inflammatory infiltrate, and tissue culture revealed no yeast or fungi. Colonoscopy revealed a large deep ulcer in the midtransverse colon and a few ulcers in the distal descending and sigmoid colon. Colon biopsies resulted as focal active colitis in the right colon, moderate active colitis with crypt abscess formation and ulceration in the transverse colon, and fragments of regenerative/hyperplastic colonic mucosa with ulceration in the descending colon. He was started on solumedrol 30 mg IV twice daily and then transitioned to oral steroids and anti-TNF-alpha therapy. The patient reported improvement in symptoms at one-month follow-up. He had a repeat colonoscopy eight months later that showed persistent active colitis that was improving, and he was continued on anti-TNF-alpha therapy (Figure 3).