SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 1 | 31 CASE REPORT b c Colonic mucosa biopsies were examined histologically and reported as showing surface ulceration, crypt branching, cryptitis and focal crypt abscesses. In addition, there were no granulomas, viral inclusions or dysplasia. Ziehl Neelsen stain for acid fast bacilli and PCR for Mycobacterium tuberculosis were both negative. Consequent tissue culture for mycobacterium tuberculosis was negative after 42 days incubation. Stool culture/ evaluation was negative for bacteria including Clostridium difficile and IgG amoebic serology was negative. Blood test results are shown in table 1. Of note was the severe anaemia (Hb 7.6g/dL), elevated C-reactive protein (95mg/L), severe hypoalbuminemia (likely protein-losing colopathy); and iron studies likely indicating combined chronic inflammation and iron deficiency. The patient also had a gastroscopy which was normal. Table 1. Blood test results Parameter Value Reference range White Cell Count (x10⁹) 12.70 3.90 - 12.60 Haemoglobin (g/dL) 7.6 12.0 - 15.0 Mean Corpuscular Volume (MCV) [fL] 84.3 78.9 - 98.5 Platelets (x10⁹) 451 186 - 454 Red cell distribution width (%) 15.9 12.4 - 17.3 Erythrocyte sedimentation rate (ESR) – mm/hr 12 0 - 10 C-reactive protein (CRP) – mg/L 95 <10 Sodium (mmol/L) 136 136 - 145 Potassium (mmol/L) 4.8 3.5 - 5.1 Urea (mmol/L) 4.4 2.1 - 7.1 Creatinine (µmol/L) 55 49 - 90 Total Protein (g/L) 51 60 - 78 Albumin (g/L) 16 35 - 52 Alanine aminotransferase (ALT) 18 7 - 35 Aspartate aminotransferase (AST) 14 13 - 35 Alkaline Phosphatase (ALP) 126 42 - 98 Gamma glutamyl transferase (GGT) 9 <40 Total bilirubin 6 5 - 21 Conjugated bilirubin 5 0 - 3 Lactate dehydrogenase (LDH) 271 100 - 190 Serum Iron (µmol/L) 2.6 9.0 - 30.4 Transferrin (g/L) 0.7 2.50 - 3.80 Transferrin saturation (%) 13 15 - 50 Ferritin (µg/L) 52 11 - 307 Vitamin B12 (pmol/L) 626 133 - 675 Folic acid (nmol/L) 11 7.0 - 45.1 Corrected calcium (mmol/L) 2.37 2.15 - 2.50 Magnesium (mmol/L) 0.62 0.63 - 1.05 Phosphate (mmol/L) 1.17 0.78 - 1.42 Lipase (U/L) 17 13 - 60 Antinuclear factor Negative (0.2) Alpha-1 anti-trypsin (g/L) 2.13 0.90 - 2.00 The patient was evaluated by Pulmonology. Further history did not reveal any overt exposures (occupational or drugs/toxins) that could be associated with pulmonary fibrosis. Routine sputummicroscopy and culture did not reveal any respiratory infections and sputum samples were negative on two separate occasions for Mycobacterium tuberculosis on polymerase chain reaction (PCR). Covid-19 PCR and anti-nuclear factor were negative; and serum alpha-1 anti-trypsin was not reduced. Spirometry showed a moderate to severe pattern of mixed obstructive and restrictive lung disease with post-bronchodilator FEV1 47% and FVC 44% of predicted; and FEV1/FVC of 92%. The carbon monoxide diffusion capacity (DLCO) was severely reduced at 29% (7.42 vs predicted 25.50 ml CO/minute/mmHg). Blood gas analysis showed a mild alkalosis and mildly reduced arterial oxygen level: pH 7.48; pCO2 5.24kPa (4.27 – 6.40); pO2 10.73 kPa (11.1 – 14.4); bicarbonate