A 19-year-old male patient with a history of perianal fistula treated with antibiotics consulted for digestive symptoms of 5 months of evolution characterized by diffuse abdominal pain of colic type and bloody stools of variable consistency, explosive.
Laboratory tests revealed hemoglobin (Hb) 11.3, sedimentation rate (SSR) 33 mm/h and C-reactive protein (CRP) 4.16 mg/L (normal value < 1).
It was decided to perform a colonoscopic study that revealed ulcers in the ileum with biopsies compatible with the diagnosis of CD, starting budesonide for 3 months and azathioprine (AZA) 125 mg/day).
After 6 months of use of AZA, the patient persisted with anemia, CRP 35 mg/L (normal value < 10) and elevated fecal calprotectin (quantitative semi > 200 ug/g) starting adalimumab.
After 15 months of treatment with biological therapy consultation for 10 days of evolution characterized by hypogastric pain, abdominal discomfort and pre and post voiding pain.
Laboratory tests revealed slightly elevated ESR and CRP (28 mm/h and 37 mg/L (normal value < 10), respectively.
Initially she received symptomatic treatment, but given the persistence of her symptoms, an abdominal-pelvis magnetic resonance imaging (MRI) was requested, which showed multifocal involvement of the terminal ileum associated with small ileocolic contrast lymphadenopathies and a real cystic hypogastric mass.
A MMPB was considered in the differential diagnosis and the patient underwent surgery.
During the procedure, after exposure of the peritoneal cavity, numerous thin-walled cysts with citrin content intensely adhered to the pelvic peritoneum, bladder and sigmoid colon were observed.
One of the cysts was resected and submitted to a rapid biopsy, reporting as mesothelioma.
Macroscopically, the appendix and the right colon showed no alterations, while the mesentery adjacent to the last 40 cm of the terminal ileum was thickened.
It was decided to perform an intraoperative wound dressing which showed ulcers in the last 30 cm of the ileum and a diaperable stenosis at this level.
The cystic lesion was carefully resected completely, the mesentery of the terminal ileum was covered and an ileocolic resection was performed with laterolateral anastomosis and manual suture.
Deferred biopsy reported a cyst of peritoneal inclusion multilocular with squamous metaplasia and expression of calretinin and cytokeratin.
The terminal ileum, ascending colon and appendix showed chronic active ulcerated ileitis with cryptic microabscesses and granulomatous transmural reaction, consistent with active CD and colonic mucosa with chronic nonspecific inflammation.
The immediate postoperative period was characterized by the presence of adynamic ileus which resolved after two days, and the patient was discharged without other complications.
It was indicated to maintain biological therapy, however, the patient abandoned the follow-up and returned after six months due to abdominal pain, diarrhea and perianal pain.
During this period the patient did not continue the suggested therapy and was only maintained with AZA in subtherapeutic doses (50 mg/day).
Pelvic MRI showed abscess and perianal fistula complex induction of hospitalization (0, sedal drainage and installation, initiating therapy with AZA 2 mg/kg/day and infliximab 5 mg/kg every 8 weeks).
