2021:
Conference title: Patient centred clinical problem solving 2021Workshop Title: Chronic diarrhoea and Malabsorption syndromeActive participants:Dr Amit Taneja, Faculty Medical College, Wisconsin
SK Biswas, Faculty, Medical College, Jinan University, Guangzhou
Aadipta Ghosh, MBBS Intern, IQ City Medical College Durgapur
Sai Charan Kulkarni , MD Medicine PGY1, KIMs, Narketpally
Dr Faraz, MD Microbology, PGY1, KIMs, Narketpally
Aditya Samitinjay, MD Medicine PGY3, KIMs, Narketpally
Dr Lakshmi Vasantha, Prof Microbology, KIMs, Narketpally
Rakesh Biswas , Prof Medicine, KIMs, NarketpallyPassive participants: 1800 asynchronous online global participants consisting of MBBS and MD students, senior residents, independent researchers and faculty Professors in global locations but maximum represented from Indian subcontinent as well as Europe, US, AustraliaConversational learning outcomes:Rakesh Biswas presents the patient data that was logged and compiled into a case report by Dr Navya, Intern :
"A young man with chronic diarrhoea and severe hypoalbuminemia and generalized body swelling patient that we are currently grappling with and will appreciate your inputs
Inputs 1 from Amit Taneja
Not my area of expertise, however this is not IBD. If you have access to EGD and push enteroscopy it will be very useful to get biopsies. Clinical diagnosis is malabsorption syndrome and/or protein losing enteropathy. Cause needs to be elucidated. Work up for sprue-tropical and celiac; pancreatic insufficiency and finally obtaining biopsy. Should also screen for HIV as that will widen the ddx
RB reply
Colonoscopy pending. Rest done and dead ends.
Inputs 2 from Amit Taneja
Rakesh Biswas what did egd and small bowel follow through or push enteroscopy show? And on biopsies
RB reply 2
Upper GI endoscopy done earlier appeared normal but small bowel enema and push enteroscopy may remain pending due to affordability constraints
RB reply 3
Amit Taneja quoting from
"The three main groups of disorders that cause excess protein loss in stools are:
1) Primary Erosive/Ulcerative gastrointestinal Disorders
This group of conditions includes inflammatory bowel diseases (both ulcerative colitis and Crohn disease), Gastrointestinal malignancies, any erosions or ulcers of stomach or duodenum, Clostridium difficile colitis, carcinoid syndrome, graft vs. host disease."
Inputs from Aadipta Ghosh
Do fecal fat studies including Sudan qualitative stain for fat, 72-hour quantitative fecal fat collection, and fecal alpha-1-antitrypsin. Also go for small bowel barium series for mucosal abnormalities typical of malabsorption syndromes
RB reply
Well take a look at the jar of "paneer curry" sign in the image uploaded in his case log
AG reply
Yes then we need to rule out non erosive causes of protein losing enteropathy and primary intestinal telengiectasia. Also rule out mesenteric tuberculosis or sarcoidosis, lymphoma
RB reply
Yes Aadipta Ghosh for biopsy one does also need to spot some macroscopic findings in the endoscopy to guide the location of the biopsy. What if the findings are in the jejunum alone? How do we visualize that area?
Two days after
RB update : Upper and lower GI endoscopy apparently normal. Now what empirical Diet therapy? 😐
Amit Taneja reply: Rakesh Biswas did they do random biopsies? And if so, were they normal?
If you have a medical student or an intern, good mental exercise for them to approach it from the angle of making a table of causes of malabsorption syndromes and protein losing enteropathies. Then crossing off the ones with normal mucosa and biopsies?? And see what we are left with??
RB reply:
Yes they did and we will need to wait for the biopsy reports but it's a great idea to see what would still show normal findings microscopically
Four days later biopsy report discussion:
RB: Check out this patient's intestinal biopsy images uploaded on the patient's case log above
SK Biswas, Prof Pathology, Jinan University, Guangzhou : few blunted villi - can it be tropical sprue with superadded giardiasis?
RB reply : Yes likely.
And the organisms could be something that resembles giardia but may be named as "spruella tropicana?"
Inputs from KIMs Microbology Hod: Sir, we did not find Trophozoites in repeat sample. We found only few cysts.Above picture is showing Trophozoites. Sir, pathology report is from our Institute ?
Rakesh Biswas: Yes KHL
KIMs Micro Hod: Ok sir. After that patient took medication?
Rakesh Biswas: No we didn't give him any medication for his giardiasis till now.
He improved on a gluten free diet so I'm not yet sure if these organisms were responsible for his problem
KIMs Micro HoD: But, histopathology picture showing Trophozoites & in our microscopy ,few cysts were seen. Definitely infection is present
Kims Aditya Samitinjay: Ma'am is it feasible to treat with a 3 week course of Metronidazole for this patient ?
KIMs Microbology HOD: I have to verify treatment guidelines
Dr Faraz : Good evening sir and ma'am. Could the intraepithelial lymphocytosis and villous atrophy present be associated with celiac disease? His improvement on a gluten free diet is also another factor pointing towards that.
Kims Aditya Samitinjay: Sir he may have improved with Racecadotril and Loperamide ?
Rakesh Biswas: 👍yes thanks for these very useful inputs.
I too think as Dr Faraaz mentions that his histopathological changes can still be explained with gluten and as three interventions had been delivered to him at the same time unless and when we can remove the racecadotril and loperamide from his regime. Let's see we will hopefully do that soon
Dr Faraz : I m not convinced with the morphology as the shape & nucleus don't look like giardiasis
May b some protozoan commensals
Kims Aditya Samitinjay: Good evening ma'am. This patient's stool microscopy report on 30th August 2019 did not show any parasites or cysts, However it showed 12- 14 WBCs/hpf. This could mean his symptoms are unrelated to this Giardiasis ? And may in fact be due to Celiac Disease ?
Kims Aditya Samitinjay: Ma'am are there any features of giardiasis which could suggest chronicity ?
Rakesh Biswas: Aditya just review the literature around histopathology of chronic giardiasis
Kims Aditya Samitinjay: Partial villous atrophy, crypt hyperplasia and monocytosis of lamina propria sir.
Rakesh Biswas: Alright so essentially all these chronic changes are not specific to any particular organism and just indicate chronic mucosal damage due non specific inflammatory response
Update four days later:
RB: Have started him on Tinidazole today but here is a preemptive read to think through and ahead into the problem https://www.sciencedirect.com/
Update 10 days later
Relapsed again today after completing five days of Tinidazole by Feb 16.
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