case_images: PMC5733168_01
case_images: Skin biopsy demonstrating a perivascular and interstitial lymphohistiocytic infiltrate with numerous eosinophils (arrow). Hematoxylin-eosin stain, 400x.
case_images: CRIGM2017-7861857.001.jpg
case_images: PMC5733168_01_CRIGM2017-7861857.001.jpg
case_images: fig1
case_images: A IgA level was <1.2 U/ml with an IgA of 292 mg/dl. A skin biopsy of the right upper extremity (Figure 1) showed prominent papillary dermal edema with spongiosis and a dense lymphohistiocytic infiltrate with eosinophils which were felt to be consistent with a drug reaction.
case_images: Localized mildly scalloped mucosa in the 2nd portion of the duodenum and granularity in the left colon.
case_images: CRIGM2017-7861857.002.jpg
case_images: PMC5733168_01_CRIGM2017-7861857.002.jpg
case_images: fig2
case_images: Upper endoscopy showed a normal appearing esophagus and stomach with localized mildly scalloped mucosa in the 2nd portion of the duodenum (Figure 2). Colonoscopy showed granularity in the left colon and a white thin exudate in the entire examined colon (Figure 2).
case_images: Biopsies of the stomach show loss of parietal cells, mild glandular disarray, acute inflammation, and apoptotic activity (hematoxylin and eosin, original magnification 200x); biopsies of the duodenum show absence of goblet cells and Paneth cells (hematoxylin and eosin, original magnification 200x); biopsies of the terminal ileum are similar to the duodenum. There is an absence of goblet cells and Paneth cells. This field shows crypt dropout as well (hematoxylin and eosin, original magnification 200x); biopsies of the colon show cryptitis and crypt abscess with minimal crypt distortion.
case_images: CRIGM2017-7861857.003.jpg
case_images: PMC5733168_01_CRIGM2017-7861857.003.jpg
case_images: fig3
case_images: Histopathological evaluation of the gastrointestinal tract revealed loss of parietal cells, mild glandular disarray, acute inflammation, and apoptotic activity in the stomach (Figure 3, hematoxylin and eosin, original magnification 200x) and patchy villous atrophy and absence of goblet cells and Paneth cells in the duodenum with crypt abscesses and apoptosis (Figure 3, hematoxylin and eosin, original magnification 200x); and in the terminal ileum, as in the duodenum, there was also an absence of goblet and Paneth cells, with crypt dropout (Figure 3, hematoxylin and eosin, original magnification 200x). Although the surface epithelium appeared attenuated, the deeper crypts had goblet cells present (Figure 3, hematoxylin and eosin, original magnification 200x).
case_images: Overall acute inflammation and fewer architectural changes than that reported in this patient's prior biopsy. The gastric biopsies show increased lamina propria chronic inflammation with only rare crypts with cryptitis and crypt abscesses. Oxyntic glands are in abundance in the gastric body biopsies; The duodenum shows both goblet cells and Paneth cells and mild villous blunting, in contrast to the marked changes seen previously; The colon shows patchy active colitis, increased apoptosis, and marked loss of goblet cells.
case_images: CRIGM2017-7861857.004.jpg
case_images: PMC5733168_01_CRIGM2017-7861857.004.jpg
case_images: fig4
case_images: Histopathological evaluation overall (Figure 4) revealed less acute inflammation and fewer architectural changes when compared to her prior biopsies but was suggestive of an evolving autoimmune enterocolopathy with villous blunting of the duodenum and absence of goblet and Paneth cells in the colon.