An unusual cause of intestinal failure

A 62 year old man with well controlled type 2 diabetes presented with abdominal symptoms, significant weight loss and night blindness. He was vitamin A deficient, had marked peripheral oedema and a serum albumin of 12g/l, requiring TPN.
Stool culture and testing for HIV and TB were negative. Immunoglobulin levels were normal.
Computed tomography showed mesenteric inflammatory fat stranding and enlarged lymph nodesĀ (Figure 1). Colonoscopy was unremarkable.
Histology revealed inflamed and ulcerated small bowel mucosa with plump endothelial cells. (Figure 2) There were no granulomata.
Enteroscopy showed granular oedematous mucosa and deep ulcerations. (Figure 3).
What is the differential diagnosis?

Gavin Stead

  • Keith Siau

    Not sure if the histology is a red herring. Would consider infiltrative causes: lymphoma, eosinophilic enteritis, autoimmune enteritis, amyloid (although unusual), as well as Whipple’s and complications of coeliac…

  • Jonathan Mark Blackwell

    Idiopathic chronic ulcerative enteritis?

  • Gavin Stead

    Perhaps DM2 can cause significant immunocompromise, even if well controlled. If so could have big implications for which patients should be considered immunocompetent and therefore what differential diagnosis to consider.

  • Miranda Geddes-barton

    Clinically this sounds like severe crohns

  • Gavin Stead

    Keith, would your list of differentials change if you were to consider the inflammaed mucosa that showed up in the histology?

  • Suzanne Tween

    Very interesting, I look forward to knowing the answer

  • Esme Siriboe

    Really interesting case! Is this IBD – Crohns?

  • Karan Nadig

    Interesting! I reckon it’s Crohn’s

  • Orla O’Connor

    Lymphoma of small bowel is my guess

  • Joseph Cooney

    A very interesting case. ? CMV inclusion bodies

  • Aaron Bancil

    I thought of CMV when you mentioned the patient being immunocompromised. Otherwise, I would have agreed with Dr Blackwell’s diagnosis. Very interesting case.

  • Julia Geddes

    Sheds new light and offers a fresh perspective on a common problem

  • Jack

    Infectious cause with something like Yersinina?

  • Sven Troedson

    An interesting case, when can we have the answer?