Mimics of Inflammatory Bowel Disease. Dr Catriona McKenzie Royal Prince Alfred Hospital, Camperdown

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1 Mimics of Inflammatory Bowel Disease Dr Catriona McKenzie Royal Prince Alfred Hospital, Camperdown

2 Mimics of IBD: Overview Infections Drugs Autoimmune Other

3 Infections Diagnostic Histopathology, 2015

4 Case 1: NSW does it better 46M Diagnosed with ulcerative colitis in the country on biopsy Refractory to treatment with steroids and infliximab Transferred to RPAH where he underwent an emergency proctocolectomy

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11 SC Previous biopsies

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13 Entamoeba histolytica Parasitic infection, orofaecal transmission 10% of world s population is infected Industrialised countries immigrants, returned travellers, MSM Symptoms vary from vague to fulminant colitis May form mass (ameboma) May disseminate (liver, CNS)

14 PLOS neglected tropical diseases, cases identified of intestinal amoebiasis with concomitant corticosteroid therapy 25% cases fatal 11 (46%) given steroids for misdiagnosed IBD Organisms identified on histology on 47% cases from endoscopic biopsies

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16 Three subsequent cases 67 M Cardiac arrest, perforation with 4 quadrant peritonitis 75 M Perforation and peritonitis

17 58 M, Caecal tumour

18 Case 2: Wear a mask 61 year old man Right hemi colectomy

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28 Further history/ subsequent No history of IBD or recent overseas travel ZN (and other organisms stains) negative Mycobacterial PCR negative Culture of peritoneal nodules negative Treated presumptively for TB course

29 20 year period 841 patients identified with TB, 2.4% abdominal involvement, <1% ileo-caecal or small bowel involvement

30 Differential diagnoses

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32 Detection of organisms with ZN and PCR in ITB Reports of AFB positivity on ZN in ITB variable 6-8% to 53.4% Reported sensitivity rate of PCR on FFPE tissue of endoscopic biopsies of ITB 22-75% Epstein et al. Aliment Pharmacol Ther 2007 Dasgupta et al. J Lab Physicians 2009

33 Aetiology of IBD

34 Case 3: Sexually transmitted infectious proctitis/colitis Syphilis and LGV/CT most commonly reported Neisseria gonorrhea

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37 56M. Diarrhoea, weight loss. Anal ulcer

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43 Diagnostic Histopathology, 2015 Infections Drugs Autoimmune Other

44 Case 4 #quite severe 69 year old man Pan colitis?toxic megacolon on imaging Known metastatic melanoma on treatment with Ipilimumab

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51 Neutrophilic infiltrates with cryptitis, crypt abcesses, +/-granulomas Lymphocytic infiltrate Mixed Increased apoptosis/gvhd like Small Bowel involvement J Gastroenterol Hepatol Apr Case Rep Oncol 2016

52 Pembrolizumab associated colitis Kim et al, AGA 2017 (abstract)

53 Pembrolizumab associated colitis Pembrolizumab (embryonal carcinoma)

54 Nivolumab (HCC)

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57 Mimics of IBD Infections Drugs Autoimmune Other

58 74F Case 5. What s missing?

59 Colonic biopsies

60 CMV

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62 Duodenal biopsies

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65 Gastric biopsy

66 Autoimmune enteropathy Rare (<1/ infants) First described in 1982 in children, now well recognised in adults Syndromic IPEX (Immune dysregulation, Polyendocrinopathy, Enteropathy and X linked) - loss of function mutations in FoxP3 APECED syndrome (Autoimmune Polyendocrinopathy Candidiasis Ectodermal Dystrophy Syndrome) Non syndromic Unsworth et al. J Pediatr Gastroenterol Nutr 4: ; 1985 Odze & Goldblum. Surgical pathology of the GI tract, Liver, Biliary tract and pancreas. 3 rd ed 2014.

67 Further history 74 F presented to Dubbo March 2014 with 3 month history of severe diarrhoea Transferred to RPA - responded to steroids, TPN and Sulphasalazine, returned to Dubbo Diarrhoea returned with fevers, complicated by documented CMV, underwent emergency colectomy and end ileostomy Steroids reduced again but high stoma output (2-3L) day re- biopsied

68 Diagnosis of autoimmune enteropathy Recommenced high dose steroids and azathioprine Plasma sent to Children s Hospital of Philadelphia for antienterocyte antibody testing (negative) Progress

69 Protracted diarrhoea Small intestinal villous atrophy Lack of response to dietary therapy Evidence of autoimmunity (circulating autoantibodies to gut epithelium/associated autoimmune diseases) Unsworth et al. J Pediatr Gastroenterol Nutr 4: ; 1985 Masia et al, AJSP 2014

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71 Case 6. What s missing #2?

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76 Stomach

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78 Duodenum

79 Ileum

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81 Diagnosis CVID.and recent c.jejuni infection

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83 Mimics of IBD Infections Drugs Autoimmune Other

84 Case 7: Diversion colitis 33 year old man. History of ulcerative colitis. Completion proctectomy

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91 Diversion colitis vs UC Odze 2014

92 Case 8 68F Stage 3 breast cancer Recent colitis diarrhoea Colonoscopy + Bx -? diverticular associated colitis. Just affects sigmoid colon. Diverticular colitis?

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96 12 months later..

97 SCAD M>F, typically elderly UC and Crohn s like changes described Usually managed conservatively Reported to precede UC and Crohns

98 Case 9 Control

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100 AGPS committee P Mckenzie J Shin T Dodds R Gupta E. Robbins L. Anderson J.Kench B. Elston T. Fuchs K. Seoane-Velilla C.Byrne C.Corte Acknowledgments