Department of Gastroenterology PROBLEM CASE A Case of Small Bowel Ulcer with Laryngeal Ulcer in 38-Year-Old Man Department of Gastroenterology

박O준 M/38 입원일 2005.01.08 2nd Admission Chief complaint : Hemoptysis - onset : 6 hours ago Present illness - 2003년 10월경부터 abdominal pain 호소하여 개인병원 에서 capsule endoscopy 시행 후 Crohn’s disease 진단 하에 PO Medication 해 오던 환자로 내원 당일 1L 정도의 hemoptysis를 지속 적으로 하는 증상을 주소로 응급실 경유하여 호흡기 내과로 입원 - 내원 약 1개월전부터 sore throat, hoarseness 호소하여 내원 하루전 ENT 외래에서 laryngeal Crohn’s disease 의심하에 1월 11일 larynx biopsy 예정되어 있었음

Past medical history DM (-) HTN (-) Tb (-) Hepatitis (-) - small bowel segmental resection due to ulcer perforation 2004. 11. Family history None Personal history Alcohol (-) Smoking (-) Current drug history Mesalazine / Prednisolone

Review of Systems General : fatigue (+) fever (+) chills (-) night sweat (-) weight loss (+) -7kg for 2 months Skin : rash (-) itching (-) pigmentation (-) Head / Neck : headache (-) hoarseness (+) sore thraot (+) Respiratory : cough (-) sputum (+) dyspnea (-) haemoptysis (+) cyanosis (-) Cardiac : orthopnea (-) chest pain (-) palpitation (-) GI : A/N/V/D/C (-/-/-/-/-) haematochezia (-) melena (-) abdominal pain (-)

Physical Examination Vital sign 110/70 mmHg – 108/min – 22/min – 38.3 °C General appearance - Alert mentality - Acutely ill appearance Skin - No rash or pigmentation Head & Neck - No cervical / supraclavicular lymph node enlargement - Neck vein engorgement (-)

Eyes and ENT - Isocoric pupils with pupilary light reflex (++/++) - Whitish sclera - Pale conjunctivae Chest - Clear breath sounds without crackle or wheezing - Regular heart beats without murmur Abdomen - Soft and flat abdomen - Normoactive bowel soud - No tenderness or rebound tenderness - No palpable abdominal mass

Back and Extremities - CVA tenderness ( - / - ) - Pretibial pitting edema ( - / - ) Neurology - Unremarkable

Initial Lab Results CBC/DC 3,800/mm3 – 11.8 g/dL– 21.4 % - 113K/mm3 (Seg 55.5%, Lymph 38.8%, Mono 3.4%, Eosino 0.1%) Chemisrty TB/DB 2.4/1.3 mg/dL ALP 670 U/L GGT 118 U/L Prot/Alb 6.4/2.6 g/dl AST/ALT 98/187 U/L LD 912 U/L Ca/P 8.3/3.2 mg/dl Bun/Cr 23/0.7 mg/dl Na/K/Cl 141/3.7/107 mmol/L ESR 14mm/hr CRP 1.9 mg/dL Urinalysis RBC 0~1/ HPF WBC 0~1/ HPF

Chest X-ray

Initial Problem Lists Hemoptysis Fever Crohn’s disease, known Hyperbilirubinemia with elevated liver enzyme level

Initial Assessment Crohn’s disease with laryngeal ulcer bleeding - with or without aspiration pneumonia Abnormal liver function due to unknown cause - due to viral hepatitis R/O Cholestasis

Initial Work-up Plan CBC F/U Chest X-ray F/U Sputum culture with AFB stain, Gram stain Blood culture Bronchoscopy Biopsy of larynx LFT F/U Hepatitis viral marker Abdominal US

Bronchoscopy – 2005. 1. 9

Laryngeal biopsy – 2005. 1. 11 Brochoscopic Biopsy Necrosis and a few of lymphoid cells

Neck and Chest CT I

Neck and Chest CT II

Clinical course I Hemoptysis due to laryngeal ulcer Result from laryngeal manifestation of Crohn’s disease - Ceftriaxone / Clindamycin - Mesalazine(Pentasa) / PDL - persistent fever (38.0~39.0°C)  Blood aspiration pneumonia or Crohn’s disease ? Abnormal LFT : Not yet identified - F/U TB/DB 1.5/0.8 mg/dL AST/ALT 69/121 U/L - Abdominal US ; Mild fatty liver with splenomegaly Refer to dep. of GI for management of Crohn’s disease

Previous Colonoscopic Finding 2004-12-13

Small Bowel Series

Clinical Course II No haemoptysis or other bleeding  Discharge 2005. 1. 18 Re-admission to GS 2005. 1. 22 due to abdominal pain - Recurrent small bowel perforation - Neck subcutaneous emphysema due to larynx perforation Small bowel segmental resection (ileum) Tracheostomy due to laryngeal perforation - Rebiopsy of larynx

Clinical Course Review 2003. 10. Crohn’s disease initial diagnosis [한솔병원] 2004. 11.17 - 1st small bowel perforation [GS] 2005. 1. 8. – Hemoptysis [Pulmo] 2005. 1. 15 – Transfer to GI 2005. 1. 22 – 2nd small bowel perforation [GS]

NK/T cell Lymphoma, nasal type Laryngeal biopsy II CD3+ NK/T cell Lymphoma, nasal type

Review of Previous Small Bowel Pathology (2004.11.18) CD56+ NK/T cell Lymphoma, nasal type

Clinical relationship with NK/T cell lymphoma Splenomegaly Weight loss ; - 7Kg for recent 2 months Persistent fever Elevation of bilirubin, AST, ALT level ?

Final Diagnosis Extranodal NK/T cell Lymphoma, with Larynx and Intestine Involvement