A 50-year-old male, diagnosed with Crohn's disease with complex ileal and perianal involvement in treatment, presented to the emergency department with fever, perianal suppuration and diarrhea for 1 week.
The patient remained on therapy with salicylates and azathioprine (2.5 mg/kg/day, adjusted according to TPMT levels) for 2 years and had received 6 doses of infliximab for months prior to admission.
On physical examination, the patient had a poor general condition, fever (39 °C), hypotension (TA 80/40 mmHg), tachycardia (104 bpm) and tachypnea (22 rpm).
The right iliac fossa showed a mass effect with increased consistency and a fistulous orifice in the left glue over an indurated, erythematous, warm area.
Urgent blood tests showed anemia (Hb 7.9 g/dl, hematocrit 29%), renal failure (creatinine 4 mg/dl) and elevated acute phase reactants (CRP 127, platelets 424,000/ml).
With the probable diagnosis of sepsis and multifactorial renal failure (salicylates, consolidation, etc.), treatment with serum therapy and broad-spectrum antibiotics was established.
During the following 24 hours, the patient developed disorientation, agitation and impairment of renal function with evident metabolic and electrolyte disturbances (urea 68 mmol/ l, creatinine 6.9 mg/ dl, sodium
In view of these results, a renal Doppler echography was performed which turned out to be anodyne, with renal failure being multifactorial in origin aggravated by the hyper-instalation crystals of mg hemodialytic acid and 1.8-hydration treatment.
However, in view of the progressive clinical status of the patient, a cluster ACT with non-pelvic worsening was performed, which showed a retroperitoneal mass of 13 x 10 cm and a lesion in the right flank of 15 x 10 cm.
Multiple adenopathies in the mesenteric, iliac and inguinal chains were also observed, as well as a left perirectal lesion, probably related to their history of abscess and perianal fistula.
The latter was the only radiological finding observed two months before the current episode, in a non-pelvic MRI scan to control perianal disease.
Despite the supportive treatment instituted, the patient continued with fever, decreased level of consciousness, progressive dyspnea and anuria, dying three days after admission to the hospital.
The definitive diagnosis was obtained after performing a necropsy: vesicular stomatitis with predominance of light chains of laminate type and cecum bone marrow terminal ileum and mesentery root, lymph node ganglion.
