A difficult case of Crohn's disease?

Abstract

A young lady with a long history of recurrent infections was referred to the gastroenterology department by an infectious disease consultant because of a long history of profuse diarrhoea. A nitroblue tetrazolium (NBT) test performed in her mid-teens had shown zero reduction of the dye. The clinical, biochemical, radiological and endoscopic findings were suggestive of possible underlying Crohn's disease. However, the NBT test was more suggestive of a granulomatous colitis which frequently mimics Crohn's disease in patients with Chronic granulomatous disease. Management with immunosuppressants is proving to be very difficult in this patient in view of recurrent sepsis on introducing these drugs.

Figure 1

MRI scan showing complex, bilateral perianal fistulae with no evidence of ischiorectal or pelvic abscesses.

Figure 2

Colon biopsy: H&E high power ×200: epithelioid granulomata with giant cells in a background of non-specific inflammation.

Figure 3

Colon biopsy: H&E high power ×200: cryptitis and crypt abscess on the left, with an increased lamina propria cellularity on the right composed of an acute and chronic inflammtory cell infiltrate.

Figure 4

Capsule endoscopy – small bowel inflammation with ulceration and stricturing visible.