Abdul H. Khan, MD; Christopher C. Thompson, MD, MHES; David L. Carr-Locke, MD, FRCPSeries Editor: David L. Carr-Locke, MD, FRCP

Disclosures

May 16, 2005

Case Report

A 49-year-old woman with a history of breast cancer was admitted to hospital complaining of abdominal cramps, nausea, and diarrhea. She had recently (about 1 month previously) taken a cruise to Mexico with her family during which time the symptoms developed. Her symptoms were mild initially but persisted, especially the diarrhea, which she described as daily watery, nonbloody stools, approximately 3-5/day. She indicated that she was treated with a course of antibiotics on the cruise, but without relief. A CT scan ordered by her oncologist showed diffuse thickening of her ascending and transverse colon, with fat stranding around the colon, but no mass lesion or signs of obstruction (Figure 1).

CT scan image showing diffuse colonic thickening.

The patient was found to have a lesion in her left breast on a mammogram taken 6 years prior to this presentation. The lesion was diagnosed as an invasive ductal adenocarcinoma with 11/16 positive lymph nodes. After surgery, radiation, and chemotherapy, she developed neuropathy and hirsutism, but was in remission until she had a recurrence in her right breast 3 years later, with 12/12 positive lymph nodes. She again underwent surgery and chemotherapy and the following year was found to have bone metastases. Since that time, she has developed peritoneal metastases without ascites. She also became thrombocytopenic and neutropenic, which was believed to be due to bone metastases. Her medical history was also significant for congenital adrenal hyperplasia for which she was chronically on prednisone therapy at a dose of 5 mg/day.

The patient was mildly dyspneic, but not in acute distress. Her temperature was 96.4° F; heart rate, 74 beats per minutes; respiration, 20 breaths per minute; blood pressure, 88/52 mmHg; and pulse oximetry, 97% on 2L/min oxygen via nasal cannula. She was anicteric with clear oropharynx, and no noted lymphadenopathy. Her lung exam revealed bibasilar rales and her heart exam revealed a regular rate and rhythm with normal heart sounds and no murmur. Her abdomen was obese, but soft with normal bowel sounds. She had mild epigastric and left lower quadrant tenderness without a palpable mass. The remainder of the physical exam was unremarkable.

Initially, electrolytes and liver function tests were normal. Her white blood cell count was 7600 cells/mm3, with 46% neutrophils; hematocrit was 27.2%. CT scan showed bilateral pleural effusions with scarring and calcified lymphadenopathy. CT scan of the abdomen again showed pancolitis with fat stranding, mainly of the right colon, suggestive of infection. Stool studies were negative for culture, ova and parasites, Clostridium difficile toxin, and fecal leukocytes. Blood cultures and urine Legionella antigen test were also negative. Chest x-ray showed multiple small lung nodules (not shown).

The patient was admitted with chronic diarrhea, fatigue, and mild hypoxia. She was started on IV fluids and placed on oxygen via nasal cannula. She underwent CT scan, and specimens of blood and stool were obtained for laboratory studies. A colonoscopy was performed which did not reveal any mass lesion or inflammation, but patches of submucosal hemorrhages were seen in multiple areas, most notably in the right colon and rectosigmoid region (Figures 2 and 3).

Endoscopic images showing submucosal hemorrhages in ascending colon/rectosigmoid colon.

Endoscopic images showing submucosal hemorrhages in ascending colon/rectosigmoid colon.

Multiple biopsies were obtained throughout the colon, including areas with submucosal hemorrhages and from normal-appearing areas as well. Biopsies from the ascending colon, transverse colon, and rectum showed diffusely infiltrating carcinoma (Figures 4-6). Further staining studies revealed that the carcinoma was positive for both estrogen and progesterone receptors (Figure 7) and negative for HER-2/ neu , the same histology as her original breast adenocarcinoma. The biopsies were negative for herpes simplex virus and cytomegalovirus.

Colonic biopsy image (10x).

Colonic biopsy image (20x).

Colonic biopsy image (40x).

Colon biopsy with positive estrogen receptor stain.

The patient was started on octreotide and diphenoxylate hydrochloride, with improvement in her diarrhea. The diarrhea was believed to be due to infiltrative cancer in her colon, and the hypoxia was due to lymphangitic spread of cancer to her lungs. The anemia was due to bone marrow metastases. She received a transfusion and was continued on oxygen via nasal cannula. Eventually, she was transferred to hospice care.

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