A Case of Protein Losing Enteropathy: Inflammatory Bowel Disease, Celiac Disease, or Something Else?
Bibliographic record
Abstract
Purpose: A 77 year old Caucasian female presented with a 6 month history of diarrhea and anasarca. Eight months ago, she had hematochezia and was diagnosed with ulcerative proctosigmoiditis based on a colonic biopsies showing mildly active chronic colitis and was started on mesalamine. She developed alopecia, hyperpigmented rash, nail dystrophy and mesalamine was stopped. Two months later, was hospitalized with worsening diarrhea, anasarca and albumin of 1.5 gm/dL (normal 3.4-4.7). EGD showed diffuse gastric nodularity, and biopsies showed hypertrophic gastropathy. Duodenal biopsies showed intraepithelial lymphocytosis, consistent with Celiac disease. Colonoscopy revealed moderately active colitis with inflammatory pseudopolyps, biopsied as active colitis. She received prednisone, albumin and diuretics with improvement in symptoms. However, got re-hospitalized 2 months later with similar symptoms. She had no family history of GI illnesses. At our institution, she appeared chronically ill and had +2 edema of both upper and lower extremities. Had alopecia and dystrophic nails. Labs showed albumin 2.4 g/dl, C-reactive protein of 27 mg/L (normal < 8), and zinc, copper, vitamin D and B12 deficiency. Normal 24-hour urinary protein. CT enterography showed hypertrophic gastric folds. EGD showed normal esophagus, diffuse inflammatory appearing polyposis in gastric body, antrum and duodenum. Colonoscopy also showed diffuse polyposis. These were all biopsied as hamartomatous polyps. Normal mucosa was also inflamed and edematous. The clinical, endoscopic, and histologic findings were consistent with Cronkhite-Canada syndrome (CCS). This rare, non-familial syndrome is characterized by diffuse hamartomatous GI polyposis (esophageal sparing) with epidermal skin changes (alopecia, onychodystrophy and hyperpigmentation). Mean age of onset is 59 years and symptoms progress rapidly. Unlike juvenile polyposis, in CCS, the mucosa between polyps is also involved. Malabsorption, bleeding, infection, and fluid losses cause most of the complications. Proposed mechanisms include mast cell dysfunction, primary immunodeficiency, or autoimmunity. The risk of colorectal and gastric cancer is increased. Treatment options include antacids, antibiotics, corticosteroids, and azathioprine. Surgery is reserved for complications like bleeding or malignancy. Two year mortality is 60% regardless of treatment. Our patient was started on a 6 week prednisone taper and maintenance therapy with azathioprine. Inherited syndromes should be considered when faced with multiple polyps during endoscopy. In the presence of protein losing enteropathy, ectodermal changes and diffuse hamartomatous polyposis, the diagnosis of CCS should be considered.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.003 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.003 | 0.002 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.001 | 0.002 |
| Research integrity | 0.006 | 0.003 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".