CASE REPORT
A 55-year-old male with a medical history of intestinal obstruction, multidrug-resistant pulmonary tuberculosis, and primary antiphospholipid syndrome with a double risk factor, along with the amputation of the left upper limb, 10, 9, and 6 years ago, respectively. The patient reported a 2-year history of chronic diarrhea with a progressive increase in frequency of liquid stools, associated with approximately 5% weight loss in the last 6 months, and edema in the lower limbs that generalized on two occasions.
On physical examination, the patient had a low normal body mass index (17.4 kg/m2), increased intestinal peristalsis, edema in the lower limbs with ++ pitting edema, decreased trophism in the examined limbs, and decreased reflexes.
Laboratory examinations revealed: HGB: 13.5 g/dl, HCT: 39.5%, Platelets: 370,000 mm3, WBC: 5910 mm3, Neutrophils: 84.1% (4970 mm3), Lymphocytes: 9.8% (537 mm3), Eosinophils: 0.3%, PT: 16.7 s, APTT: 37 s, INR: 2, Glucose: 78 mg/dL, Creatinine: 0.54 mg/dL, Serum Albumin: 1.45 g/dL, Total Proteins: 4.12 g/dL, BT: 0.80 mg/dL, BD: 0.34 mg/dL, BI: 0.45 mg/dL, AST (TGO): 27.63 U/L, ALT (TGP): 30.38 U/L, Urea: 18 mg/dL, LDH: 414.30 U/L, Cholesterol: 160 mg/dL, Triglycerides: 130 mg/dL, LDL: 90 mg/dL, HDL: 30 mg/dL, GGT: 4 U/L, Sodium: 137 mEq/L, Potassium: 3.1 mEq/L, Corrected Calcium: 8.6 mg/dL, Chloride: 96.7 mEq/L, Vitamin B12: 50 pg/mL (Reference Range: 197-771), Procalcitonin: 0.37 ng/mL, CRP: Negative, Rapid Test: Non-Reactive, General Urine Examination: Yellow/Turbid, Density: 1015, pH: 6.0, Absent Proteins, Leukocytes: 1-3 x HPF, Erythrocytes: 0-1 x HPF, Bacteria: Absent, 24-Hour Urine Proteins: 98 mg/24 hours, General Stool Examination: Brown color, liquid consistency, negative occult blood, no bacteria, parasites, or yeast, Stool Culture: no growth in 24 hours, Kinyoun Stain: negative, Xpert Clostridioides difficile in stool: C. difficile toxigenic negative and 027 presumptive negative, Xpert MTB-RIFG4 in stool: MTB Negative, RIF Resistance: Not detected. Fecal Calprotectin: 75 ug/g. Serology for celiac disease was performed: ASCA, Anti-TG2 IgA, Anti-DPG IgA, EMA IgA, all with negative results. p-ANCA: Negative. Anti-transglutaminase IgA (CLIA): 3.3 U, Complement C3: 0.8 g/L (Reference Range: 0.9 - 1.8 g/L), Complement C4: 0.2 g/L (Reference Range: 1 - 4 g/L), profile of antibodies against extractable nuclear antigens: negative, Anti-dsDNA: 11.6 (Reference Range: > 27), AntiSmith: 12.7 U/mL (Reference Range: < 15), ANA: Negative. IgA: 260 mg/dL (Reference Range: 40-230), IgE: 44.7 mg/dL (Reference Range: 50-100), IgG: 600 mg/dL (Reference Range: 700-1600), IgM: 13.60 mg/dL (Reference Range: 40-230).
Imaging examinations: Abdominal computed tomography (CT) showed no abnormalities. Upper gastrointestinal endoscopy was unremarkable, and lower gastrointestinal endoscopy revealed Dispersed white spots with a ’snowflake’ appearance at the level of the terminal ileum were observed (Figure 1). A biopsy was taken, and the report indicates dilation of vessels with a lymphatic appearance in the lamina propria, associated with a moderate amount of plasma cells and distortion of the villi: Intestinal Lymphangiectasia (Figure 2). A nuclear medicine study was conducted: a scintigram for the detection of intestinal protein loss revealed an abnormal concentration of the radiotracer in the left flank in intestinal projection in the late views, confirming intestinal protein loss (Figure 3).