PMC3794984_01
Multiple images from EGD procedures. (A) EGD image from September 2008 showing a normal gastric antrum. (B) EGD image from September 2008 showing mucosal swelling near the gastric antrum. (C) EGD image showing three discrete patches of inflammation in the duodenum. (D) EGD image from September 2008 showing inflammation and ulceration in the jejunum. (E) EGD image from November 2008 showing inflammation, hyperpigmented mucosa, and erythematous mucosa in the duodenum. (F) EGD image from November 2008 again showing duodenitis.. Abbreviation: EGD, esophagogastroduodenoscopy.
imcrj-6-065Fig1.jpg
PMC3794984_01_imcrj-6-065Fig1.jpg
f1-imcrj-6-065
In September 2008 he underwent endoscopic studies which revealed a hiatal hernia, old blood in the stomach, mucosal swelling near the gastric antrum, and three areas of circumferential ulceration and inflammation with mucosal pigmentation/erythema (see Figure 1). He then underwent repeat endoscopy which showed normal gastric mucosa, but granular and unusually pigmented duodenal mucosa (Figure 1).
Hematoxylin and eosin stains of mucosal biopsies from esophagogastroduodenoscopy and trichrome stain of renal biopsy showing pauci-immune crescentic glomerulonephritis. (A-C) Multiple slides of jejunal mucosal ulcer with nonspecific inflammatory infiltrate without any bacteria, cryptitis, crypt abscesses, or evidence of vasculitis. (D) Trichrome stain from renal biopsy specimen showing a fibrocellular crescent consistent with rapidly progressive crescentic anti-neutrophil cytoplasmic antibody-positive-associated glomerulonephritis.
imcrj-6-065Fig2.jpg
PMC3794984_01_imcrj-6-065Fig2.jpg
f2-imcrj-6-065
Slides from a macroscopic jejunal ulcer seen on endoscopy (Figure 2) showed inflammation but no features typical of inflammatory bowel disease. Given the unexplained nature of his systemic symptoms, acute kidney injury, and the positive c-ANCA, a kidney biopsy was performed and showed rapidly progressive glomerulonephritis due to pauci-immune crescentic glomerulonephritis with 25% crescents (Figure 2).