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.