Transient Mimickers of Crohnʼs Disease

Abstract

We present 3 cases with initial clinical and pathological findings consistent with Crohn's disease who are currently clinically well despite no medical therapy, prompting the question, "Are there transient mimickers of Crohn's disease?" Case 1: A 14 year old female presented with right sided abdominal pain, a painful "hemorrhoid" and intermittent blood in the stool. Physical examination revealed a perianal skin tag. Lab evaluation revealed mildly elevated ESR of 26 mm/h and equivocal anti-Saccharomyces cerevisiae IgG. Esophagogastroduodenoscopy (EGD) and colonoscopy revealed gastritis and terminal ileal disease. She was treated with metronidazole, budesonide, mesalamine and a proton pump inhibitor. Parents made dietary changes, removing all additives and preservatives from the diet. After 6 months, unconvinced this was Crohn's, they discontinued all medications. One year off treatment she remained clinically well. Repeat colonoscopy was grossly and histologically normal. Case 2: A 12 year old male presented with a 3 week history of abdominal pain, fatigue and weight loss. Lab evaluation revealed anemia, thrombocytosis and hypoalbuminemia, ESR 32 mm/h, CRP 20 g/dL, amylase and lipase 833/1850 Unit/L respectively. EGD and colonoscopy revealed histological evidence of Crohn's disease in the esophagus, stomach and small intestine. Imaging studies failed to demonstrate any anatomic cause for pancreatitis. The patient was treated with mesalamine and subsequently azathioprine. After 10 months, infliximab therapy was recommended due to persistently elevated inflammatory markers and pancreatic enzymes as well as hypoalbuminemia despite treatment. Parents declined, discontinued all medications and placed him on oral supplements including fish oil and "Intestinew". At two years all labs normalized and the patient remained clinically well. Colonoscopy was never repeated. Case 3: A 16 year old female status post total colectomy with Duhamel procedure for Hirschprung's disease in infancy presented at age 8 with diarrhea, abdominal pain, hypoalbuminemia, and elevated ESR. On enteroscopy ulcerations were found in the terminal ileum. Histology revealed chronic inflammation consistent with Crohn's disease. Her response to corticosteroids and immunomodulators was poor. She developed severe borborygmi. After discussion with the surgical team, it was felt that her Duhamel was dysfunctional. A diverting ileostomy was performed with resolution of symptoms. Repeat ileoscopy revealed no ileal ulcerations. ESR and albumin normalized. Most likely ulcerations were secondary to chronic partial obstruction and severe bacterial overgrowth. Twenty five percent of Inflammatory bowel disease (IBD) is diagnosed in the pediatric age group. Following clinical, radiological and histological evaluation, a diagnosis of IBD is rendered. It is a lifelong disease with no cure. Our cases illustrate that there may be other diseases that mimic Crohn's disease at the initial onset but do not follow the typical natural history of Crohn's disease. These cases serve as a reminder that Crohn's disease can be a challenge to diagnose even for the most astute clinician. Advances in serologic and genetic testing, as well as imaging increase the likelihood of making a correct diagnosis. Nonetheless, as the above cases illustrate, 100% certainty is not always possible.