10 proteinlosing enteropathy 7 Albumin scan albumin loss

현병력 ü 10년 전, 수양성 설사와 전신 부종으로 외부 병원에서 protein-losing enteropathy로 진단 받음. ü 7년 전, 증상 지속되어 본원 방문. • 진단 검사 à Albumin scan: albumin loss at RLQ à SBS: diffuse thickening of small bowel short stenosis in distal ileum • 치료 경과 à R & A: caseating granuloma, c/w tbc à 항결핵 치료 시작

계통적 문진 및 신체 검진 ü 계통적 문진: 특이 사항 없음. ü 172 cm / 63 kg ü V/S 115/82 mm. Hg - 88/min - 16/min - 36. ℃ ü Abdomen • Slightly distended ü Back & extremity • Pitting edema (+/+) • Left inguinal area: excision scar

Initial Assessment ü Anal cancer • S/P chemo. RT • Recurrence at left inguinal LN ü History of tuberculous enteritis • S/P R&A • S/P short-term antituberculosis chemotherapy ü Diarrhea with edema: maybe from PLE • R/O recurrence of tuberculosis ? • R/O other disease ?

Initial Plan ü Recurred anal cancer • Evaluation of disease extent • AP CT scan • CPA • Chemotherapy vs. RT ü Diarrhea with edema • Stool exam • Colonoscopy • SBS

진단 검사 결과 ü CBC 4, 200 - 13. 8 - 308, 000 (N 71. 8%, L 10. 5%, M 11. 0%, E 6. 5%) ü LFT 17/19/116 -0. 4 pro/alb 3. 4/1. 5 chol 126 ü BUN/Cr 15/0. 7 ü Ascites exam • • RBC 90, WBC 220 (N 2%, L 7%, H 91%) protein/albumin 0. 7/0. 3, glucose 215, LDH 47 No OB/AFB No malignant cell ü CPA, stool, colonoscopy: non contributory

Abdominopelvic CT R/O 2 ndary change from hypoalbuminemia > R/O Infiltrative disease such as amyloidosis <

Small Bowel Series R/O 2 O from hypoalbuminemia > R/O Tb recur R/O amyloidosis

Reassessment & Replan ü Recurred anal cancer • Limited to left inguinal LN RT ü Diarrhea with edema • Diffuse small bowel wall thickening on imaging • R/O Tbc recurrence ? • R/O Some infiltrative disease ? • Diagnostic plan ? enteroscopy

Double Balloon Enteroscopy • Evaluation down to mid ileum • R/O Lymphangiectasia

Pathology c/w intestinal lymphangiectasia

Final Diagnosis ü Recurred anal cancer ü Protein losing enteropathy from intestinal lymphangiectasia • Underlying cause • RT +/- chemotherapy ? • Tbc sequela ? • ? ? ?