Teaching cases
Pseudomembranous collagenous colitis with superimposed drug damage

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Abstract

Pseudomembranous collagenous colitis is a rare pathological condition, not related to infectious agents, and characterized by thickening of the subepithelial collagen and formation of pseudomembranes. We report one such case, which responded to budesonide treatment after failures of previous approaches given, being unaware of the correct diagnosis.

Introduction

Microscopic colitis (MC) is an idiopathic clinical-pathological entity that consists of chronic watery diarrhea, normal or almost normal endoscopic appearance of the colon, and two histologic patterns: lymphocytic colitis (LC) or collagenous colitis (CC) [4]. The main difference between LC and CC is represented by the presence of collagen deposition immediately beneath the epithelial basement membrane in CC [4].

Collagen deposition has been considered as a phenomenon secondary due to a chronic inflammatory process, forming an anatomical barrier for fluid absorption and causing watery diarrhea [9], or as a process coexisting with the collagen as the cause of diarrhea. The relationship of LC with CC is still not well understood, and some authors consider the two processes as a continuum, LC being an early manifestation of CC [13].

The term pseudomembranous colitis has been used to describe not only the diarrheal syndrome following antibiotic use, often secondary to superinfection by Clostridium difficile [10], but also any mucosal exudative process recognized by the endoscopy or histology. Pseudomembranes have been described in ischemic bowel disease, uremia, irradiation or chemotherapy, and secondary to some bacterial infections, most notably verocytotoxin-producing Escherichia coli 0157-H7 [10].

Pseudomembranous collagenous colitis is a rare distinct entity, described in the last decade, not related to the use of drugs and to superinfections, and characterized by thickening of the subepithelial collagen and formation of pseudomembranes [5], [16], [17]. Here we describe one such case.

Section snippets

Clinical history

A 76-year-old woman who complained of watery diarrhea for one month, without hematochezia, abdominal pain or weight loss, was evaluated. The patient had no significant past surgical or medical history, except for hypertension treated with irbesartan and depressive syndrome treated with escitalopram. Further inquiry concerning use of nonsteroidal anti-inflammatory drugs, including over-the-counter self medications, was negative. Physical examination was unremarkable; blood chemistry revealed

Discussion

The pathogenetic mechanisms of CC are still poorly understood. The well-known association between CC and autoimmune diseases such as thyroiditis, arthritis, celiac disease and idiopathic inflammatory bowel diseases suggests an immunological pathogenesis of the disease [4]. However, other etiological factors have been proposed, including bacterial cytotoxins and local agents. In addition, non steroidal anti-inflammatory drugs have been also implicated in the pathogenesis of CC [2].

There are

Conflict of interest statement

None declared.

References (17)

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