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Crohn’s Disease Presenting as Intestinal Parasites
“I got worms…”
Poster by Jared Halterman, Kade Rasmussen DO, and Joseph Dougherty DO
A 14 year-old male with abdominal pain and vomiting for
three days was transferred from a rural ER to the
emergency department at a tertiary children’s care
center with the diagnosis of parasitic worm infection of
the small bowel. The patient had initially presented to
the transferring facility the previous day. Based on
physical exam he was diagnosed with gastroenteritis
and discharged home. He returned the next day with
worsening symptoms. Labs and CT scan of the
abdomen were performed, leading to diagnosis and
transfer.
Crohn's Disease (CD) is an inflammatory, immune-mediated
condition which may affect any portion of the GI tract from the
mouth to the anus, most commonly the ileum and cecum
(50%). Pathophysiology is not clearly defined, but likely
involves both genetic and environmental factors. Incidence is
5-10 cases per 100,000 with app 25% occurring children
younger than 18.
Presentation is variable and often nonspecific. In children
intestinal symptoms include growth failure, weight loss,
diarrhea, abdominal pain, abdominal mass, bowel obstruction,
rectal bleeding. Extraintestinal manifestations include fever,
arthralgias, uveitis, anemia, clubbing, oral ulcers. Diagnosis
typically involves extensive workup to rule out other diseases.
Pertinent medical and social histories were negative
except for a recent trip to Puerto Rico two months prior.
On exam vitals were within normal limits, membranes
were slightly dry. There was periumbilical tenderness
with rebound and guarding. Discs with CT imaging
accompanied the patient and were reread by pediatric
specialists. Impression was as follows;
“Dilated loops of small bowel at the level of the terminal
ileum with wall thickening, multiple ovoid shaped
densities with peripheral lucency/gas in the distal small
bowel, probable resulting in obstruction at the level of
the terminal ileum/ileocecal valve. These intralumenal
densities could represent parasitic disease or represent
retained ingested material. The colon is collapsed and
there is free fluid in the abdomen and pelvis. There are
multiple mesenteric nodes which may be reactive.”
In the ED the patient received pain medications, IV
fluids and an NG tube placed. Patient was taken by
surgery for an exploratory lap, the end result of which
was ileocecectomy with anastamosis. Pathology of the
removed segment showed full thickness colitis with
granulation tissue, and retained vegetable material.
Final diagnosis was new onset Crohn’s Disease leading
to small bowel obstruction.
Incorrect initial diagnosis is not uncommon due to the
variability in early symptoms, though possible parasitic
infestation is presumed to be a less common presentation.
That we are aware, our patient denied typical previous signs
or symptoms before presenting with SBO secondary to
terminaI iliel inflammation requiring ileocecectomy.
Cobblestoning inflammation
Terminal Ileum w/ granulation tissue, gross and on microscopy
Treatment is based on symptoms and consist of diet control,
anti-inflammatory medications (sulfasalazine, corticosteroids),
immunosupressents (azathioprine), antibiotics when
necessary, anti-diarrheals or laxatives, pain control and
surgery as a last resort.
References:
1 Griffiths, AM, Hugot, JP. Crohn Disease. In: Pediatric Gastrointestinal
Disease: Pathopsychology, Diagnosis, Management, 4th ed, Walker,
WA, Goulet, O, Kleinman, RE, et al (Eds), BC Decker, Ontario, 2004. p.
789.
2 Galbraith SS, Drolet BA, Kugathasan S, et al. Asymptomatic
inflammatory bowel disease presenting with mucocutaneous findings.
Pediatrics 2005; 116:e439.
3 http://www.cdc.gov/ibd/
4 http://www.mayoclinic.com/health/crohns-disease/DS00104
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