Case Report:
A 59-year-old female had an abrupt presentation of diarrhea, abdominal
discomfort, weight loss and several large spontaneous ulcerations on the
abdomen, limited within scar tissue from a remote bowel perforation
surgery (Figure 1a). The combination of diarrhea and ulcerations was
concerning for inflammatory bowel disease, pyoderma gangrenosum, or
malignancy. Laboratory investigations demonstrated anemia and
electrolyte derangements to include hyponatremia, hypocalcemia,
hypokalemia, and hypomagnesemia. Chronic diarrhea work-up was negative,
but lactoferrin and calprotectin were elevated (Table 1). A punch biopsy
at the edge of an ulcer showed extensive dermal fibrosis with chronic
inflammation, numerous eosinophils and granulation tissue (Figure 1bc).
PAS and Lu-5 cytokeratin stains were performed and were unremarkable.
The lack of acute or granulomatous inflammation made infection less
likely. Otherwise, the classical features of pyoderma gangrenosum,
infection, and malignancy were not appreciated. Endoscopy was notable
for duodenal villous atrophy, edematous mucosa with scattered area of
loss of vascular pattern and ulceration in the proximal colon but
histology demonstrated benign colonic mucosa. After months of otherwise
unremarkable exhaustive evaluation there was no clear underlying cause.
Of note, the patient had been treated with losartan for more than
10-years for hypertension and given the reports of ARB induced
sprue-like enteropathy, losartan was discontinued in October 2019. On
follow up one month after medication was discontinued patient noted
improvement of the diarrhea and the wounds started healing. Patient
followed up with wound care and over the next several months the wounds
completely resolved as well as her gastrointestinal symptoms. (Figure
1c).