PMC7186448_01
Timeline.
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F1
The timeline from presentation to completion of his treatment is outlined in Figure 1.
Abdominal ultrasound. Marked thickening of colon loops within mid epigastric and left upper quadrant representing transverse (see blue arrows) and descending colon.
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F2
A repeat ultrasound of the abdomen showed a markedly thickened transverse and descending colon (see Figure 2).
Abdominal CT with contrast. Marked bowel wall thickening of left colon (see blue arrows) extending from the distal transverse to the descending colon. There is an area of spared bowel in the mid descending colon. The thickened bowel is homogenous in attenuation, with relative hyper enhancement of the mucosa. There is abrupt transition between normal and abnormal bowel (shouldering). There is involvement of the serosa with multiple serosal nodules and infiltration of the pericolonic fat.
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F3
A subsequent urgent CT abdomen with contrast confirmed a markedly abnormal transverse and left colon with extensive low attenuation bowel wall thickening (see Figures 3, 4).
Same as Figure 3.
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F4
A subsequent urgent CT abdomen with contrast confirmed a markedly abnormal transverse and left colon with extensive low attenuation bowel wall thickening (see Figures 3, 4).
HE stain of bowel biopsy. Cores of fibrous tissue with extensive necrotizing granulomatous inflammation with many foreign body type multinucleated giant cells (see red arrow) and large numbers of eosinophils.
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F5
The histological examination of the bowel biopsies was highly suspicious of an infectious process with sheets of eosinophils, giants cells and granulomas with a necrotic center (see Figure 5).
Resected left hemicolon.
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F6
The resected specimen (see Figure 6) was sent for microbiology and histology and a peritoneal swab sent for microbiological analysis.
HE stain of the excised bowel. Splendore Hoeppli (see red arrow).
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F7
Grocott stain of the excised bowel. Basidiobolus hyphae (see red arrow). Typically thin-walled, septated hyphae, haphazardly branching, surrounded by eosinophilic material.
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F8