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).