A seventy three old female renal transplant recipient had received Anti-thymocyte globulin (ATG) induction and recently received OKT3 for severe acute rejection. She presented with abdominal pain and foul smelling watery diarrhea. Examination revealed tenderness over both flanks. After admission she developed fever, leukocytosis and hematochezia. The pain worsened and she also developed abdominal distension. CMV antigen was negative and stool for Clostridium difficile toxin was negative. Abdominal computerized tomographic (CT) Scan was performed.
Identify the lesion.
What is the next investigation you would like to request?
The CT Scan shows severe thickening of the right colonic wall which is almost obliterating the lumen.
Next investigation is likely to be a colonoscopy. In this case, only a limited sigmoidoscopy was possible, which revealed severe mucosal edema with superficial ulceration. Mucosal biopsy showed it to be non-specific colitis.
Immunocompromised patients can develop infectious colitis with opportunistic organisms like Cytomegalovirus, Yersinia More Details, Cryptosporidium, Clostridium difficile and Microsporidia. However, non-opportu nistic organisms like Shigella, Salmonella More Details, Entamoeba, Escherichia More Details coli can also cause colitis. Enterohemmorrrhagic E. coli is well known to cause pan colitis with pseudomembrane formation and predominant right side involvement as seen in this case. Inflammatory bowel disease like ulcerative colitis should show wall thickening with formation of crypt abscess on biopsy. Non infectious causes like ischemic colitis are localized, and should be suspected in elderly patients.
Correspondence Address: Avneesh Kumar Hamed Al Essa Organ Transplant Center, P.O. Box 1972, 92400 Al Ardiya Kuwait