PMC7396044_01
Computed tomography angiogram with contrast of the abdomen and pelvis demonstrating atherosclerotic disease of the abdominal aorta without involvement of major arterial supply of the intestine (a) and pericolic fat stranding with wall thickening of the right hepatic flexure (b).
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He was empirically started on antimicrobials and underwent repeat imaging with the computed tomography mesenteric angiogram that demonstrated only moderate features of atherosclerotic disease with patent celiac, superior mesenteric artery (SMA), and inferior mesenteric artery (IMA) (Figure 1(a)). Additional findings included features of colitis with pericolic fat stranding in the distal ascending, transverse, and proximal descending colon (Figure 1(b)).
Images from colonoscopy demonstrating multiple lesions including obstructing circumferential lesion in the ascending colon (a, b) and circumferential but nonobstructing lesion in the transverse colon (c).
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He underwent repeat colonoscopy showing similar findings (3 regions of circumferential ulceration in the ascending/hepatic flexure, splenic flexure, and descending colon) (Figures 2(a)-2(c)).
(a) Ragged colonic mucosa from the circumferential lesions biopsied during colonoscopy. (b) A high power view of a sevelamer crystal on hematoxylin and eosin-stained (H&E) slide with characteristic "fish scale" morphology and yellow/gold color. Both sevelamer (Figure 3(b)) and sodium polystyrene sulfonate have similar "fish scale" morphology and are nonpolarizable by polarized light microscopy. The primary morphologic difference between these two crystal types can be seen on standard H&E-stained slides. Sevelamer crystals can be distinguished by yellow/gold color when compared with sodium polystyrene sulfonate crystals, which show dark violet staining.
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Biopsy histology demonstrated ragged colonic mucosa with ulcerative debris and nonpolarizing crystalline material at the sites of ulceration (Figures 3-5).
Image from histology demonstrating ulcerated colonic mucosa with adherent fibrinous exudate (yellow arrows) in the presence of sevelamer crystals (red arrow) seen in the top right corner.
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Biopsy histology demonstrated ragged colonic mucosa with ulcerative debris and nonpolarizing crystalline material at the sites of ulceration (Figures 3-5).
Image from histology demonstrating active colitis (yellow arrows) again in the presence of sevelamer crystals (red arrow) as previously seen, top left corner.
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Biopsy histology demonstrated ragged colonic mucosa with ulcerative debris and nonpolarizing crystalline material at the sites of ulceration (Figures 3-5).