Results
A 12-year-old African American female presented to an urgent care clinic
with one week of nausea and vomiting. She reported fatigue and chronic
intermittent cramping abdominal pain for four months and unintentional
weight loss of 25 pounds over the last three. On exam she had pale
conjunctiva, tachycardia and mild abdominal pain.
CBC revealed hemoglobin 7.3 g/dL (nL: 12.0–16.0), hematocrit 29.7%
(nL: 36.0–46.0), MCV 62 fL (nL: 78.0–98.0), RDW 18.9% (nL:
11.5–14.5) and platelets 708 K/uL (nL: 150-450). Serum iron was 10
ug/dL (nL: 30-160), TIBC 304 ug/dL (nL: 265–497), iron saturation 3%
(nL: 20–50) and ferritin 5 ng/mL (nL: 16.0–300.0)
The patient had a positive fecal occult blood test (FOBT), suggesting
iron-deficiency anemia due to chronic intestinal blood loss. C-reactive
protein (CRP) was 3.01 mg/dL (nL: 0.0–0.9). There was initially concern
that the patient may have inflammatory bowel disease (IBD) given her
iron-deficiency anemia, elevated CRP and positive FOBT with the weight
loss and diarrhea. NSAID-induced gastritis was also considered given
daily NSAID use for abdominal pain.
Upper gastrointestinal endoscopy was performed which showed no
abnormalities. Colonoscopy showed a large, fungating, non-obstructing
~7 cm cecal mass (Figure 1). The remainder of the colon
was normal. Biopsy of the mass was consistent with UPS. Tumor
cells were weakly positive for SATB2, negative for Keratin OSCAR,
Keratin AE1/AE3, desmin, myogenin, SMA, SOX10, S-100, CD34, WT-1, SALL4
and EMA. Computed Tomography (CT) of the abdomen and pelvis noted a
cecal mass and multiple enlarged pericolonic and mesenteric lymph nodes.
CT chest with contrast revealed a solid noncalcified subpleural nodule
(1.1cm) in the posterior inferior left lower lobe (LLL). Positron
Emission Tomography (PET) scan showed positive uptake in the right colon
mass and possible uptake in the mediastinum and LLL.
A formal right hemicolectomy was performed without complication. At the
time of surgery, an intraluminal cecal mass was noted to be causing
colo-colonic intussusception. The ileal and colon margins were negative
for malignancy. Thirty-nine regional lymph nodes were sampled and
returned negative.
After recovery from the colectomy and pathology review, the patient
underwent a video-assisted thoracoscopic surgery and wedge resection of
the pulmonary nodule. Pathology on the nodule identified a 1.1 cm
necrotizing granuloma. Small yeast with narrow-based budding without a
mucicarmine-positive capsule were confirmed with GMS and PAS-F
cytochemical stains. The pathological findings of the nodule were
consistent with Histoplasma capsulatum and the patient completed
a six month course of itraconazole.
On a follow-up MRI of the abdomen 2 months post-operatively, there was
no evidence of disease and anemia had resolved.