Virtual Fellows Case Conference

A deceiving case of diarrhea

Presentation 1: Tuesday, Nov. 5

By Rishika Chugh, MD
Clinical Gastroenterology & Hepatology Fellow
Yale University School of Medicine

A 44-year-old Caucasian male and director of a Northeast dredging company presented with five weeks of watery non-bloody diarrhea and thirty pound weight loss.  Patient reported abrupt onset diarrhea with fifteen watery bowel movements per day and no prior history of abnormal bowel movements.

He underwent a complete infectious workup including stool studies (Clostridium difficile, viruses, ova and parasites, and bacteriology culture). Further evaluation for malabsorptive and metabolic etiologies for diarrhea was performed and noted to be negative. Upper endoscopy and colonoscopy both revealed a normal endoscopic exam. Pathology from the stomach and colon were normal. However, histology from duodenal biopsies revealed presence of intraepithelial lymphocytes and preserved villous architecture. On further review, patient revealed that there was a recent Cyclospora outbreak and that a co-worker was also admitted with diarrhea and a forty pound weight loss.

The patient’s stools were subsequently sent for Cyclospora/isospora testing with modified acid-fast stain at two different institutions with negative findings. The patient remained hospitalized for a week and developed acute renal injury due to gastrointestinal losses and persistent symptoms, not controlled with loperamide or empiric treatment with ciprofloxacin and metronidazole.

Question

What would be the next step in management?

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How it works

  1. Trainees with accepted submissions post the case study and question to the AGA Community as assigned.

  2. They host a two-day discussion in the all-members forum.

  3. Concluding the presentation, they share their response to the question with supporting resources.