History
A 53-year-old Chinese man with previous good health presented with a 6-month history of diarrhoea, weight loss, poor appetite and malaise. Colonoscopy showed a 40cm long segment of cobblestoning, with circumferential narrowing and ulceration in the descending colon highly suspicious for colorectal malignancy (Figure 1.1). A left hemicolectomy was performed. Histology showed ulcer exudates with granulation tissue. It was negative for malignancy and tuberculosis. He was well for 3 months after the operation, but now presents again with increasing diarrhoea up to 3-4 times per day, together with painful swallowing and tongue pain.
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What is your differential diagnosis?
The differential diagnosis includes Crohn’s disease, malignancy, tuberculosis of the intestinal tract and Behçet’s disease.
Physical examination
•Temperature 37.7°C, pulse 80 bpm, BP 120/75mmHg, SaO2 99% on RA.
•Mild pallor.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•On examination of the head and neck, there is a left tongue base mass with ulceration and right supraclavicular lymph nodes which are firm in consistency and around 1cm in size.
•Cardiovascular: HS dual, no murmur.
•His chest is clear on auscultation.
•Abdominal examination reveals a midline laparotomy scar. The abdomen is soft, non-tender, with no definite abdominal mass palpable.
•No signs of oedema.
Does this narrow your differential diagnosis?
Recurrence of colorectal malignancy is less likely in this context as metastatic lymph nodes will more commonly cause enlargement of the left supraclavicular lymph node, i.e. Virchow’s node (Troisier’s sign). However, the lymph nodes and tongue base lesion are also atypical for Crohn’s disease. Initial testing for tuberculosis is also negative and there are no other features suggestive of Behçet’s disease.
Investigations
•CBC:
–WBC 11.9 x 109/L;
–haemoglobin 10.9g/dL (microcytic, hypochromic picture);
–platelets 348 x 109/L.
•ESR 67mm/hr.
•CRP 64.5mg/L.
What other blood tests would you order?
•Liver and renal function tests.
•Bone profile.
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