A 51-year-old male patient was admitted to our hospital with aggravated bloody stool and diarrhea for 2 months, accompanied with fever, left lower abdominal pain and tenesmus. 4 years before admission, the patient was diagnosed with “colitis” for the similar symptoms not so serious without fever in other hospital. Although mesalazine had been prescribed, he had given up medications and follow-up visit without a doctor’s recommendation before admission. Laboratory tests showed elevated C reactive protein (CRP) of 35.8 mg/L. Hemoglobin was decreased at 125g/L. Colonoscopy revealed extensive colitis, with wide mucosal defect and spontaneous bleeding in the sigmoid colon (Fig. 1A). No obvious abnormality was found on chest CT (Fig. 1B). Cytomegalovirus (CMV) inclusion bodies showed positive. After intravenous ganciclovir and methylprednisolone, the symptoms did not improve. Hence, the patient was sequential to infliximab. Although the stool returned to normal with improvement of laboratory tests and lesions under colonoscopy (Fig. 1C) after infliximab treatment for 4 times, the patient still had a fever (the temperature is about 38℃). Rechecked of the chest CT showed a mass shadow right lower lung lobe (Fig. 1D). After antibiotic was administrated according to the drug sensitivity results of sputum culture (which showed acinetobacter baumannii was positive), the patient no longer had a fever, but there was no change in the lung mass. What is the diagnosis?
The colon lesions were diagnosed as ulcerative colitis (UC). Puncture and biopsy of the lung mass guided by B-ultrasound revealed granulomatous inflammation and necrosis, with multiple variable size encapsulated yeast cells present in hematoxylin and eosin staining, hexamine silver staining and periodic acid-schiff staining (Fig. 2A-C)), the final diagnosis is cryptococcus neoformans pneumonia. After the diagnosis was confirmed, antifungal treatment with voriconazole (0.2g oral bid) was given. The medicine for UC was changed to vedolizumab and the patient had no bloody stool, with the ESR and CRP normalized. After vedolizumab treatment for 3 times, reexamined colonoscopy showed a slight pseudomembranous colitis in rectum sigmoid colon (Fig. 2D), followed a positive results of fecal Clostridium difficile toxin test. The patient then received oral vancomycin for 14 days. After 3 months of treatment with voriconazole, the lung lesions were absorbed mostly (Fig. 2E). At present, the patient continues to take voriconazole orally and receive vedolizumab treatment according to the course of treatment. There is no cough, expectoration, fever, bloody stool or diarrhea.