Atypical presentation of Crohn disease in an Asian-Indian patient.

To the Editor: Crohn disease (CD) is rare in Asian-Indian populations compared with developed countries; however, recent reports have suggested that the incidence is on the rise. (1) Acute massive gastrointestinal hemorrhage is a rare complication of CD and is very rarely the first presenting feature. (2) We hereby report the first case of acute massive gastrointestinal bleeding as a primary presentation of CD in an Asian-Indian patient.

A 27-year-old healthy Asian-Indian male was brought to the hospital after having two large dark-colored bowel movements associated with a near syncopal event. He had arrived in the USA from India a week before this presentation for a business trip and described it as being "stressful." Examination was significant for orthostatic hypotension, mild tenderness in the right lower quadrant and positive stool occult blood test.

On laboratory investigations, he had severe anemia (hematocrit 26%). Stool studies were positive for stool leukocytes and negative for ova, parasites, bacterial cultures and Clostridium difficile toxin. The patient was given blood transfusions and underwent an esophagogastricduodenal endoscopy which was unremarkable. Colonoscopy revealed multiple ulcerations in the cecum and distal ileum without any ongoing bleeding. Biopsies from these ulceration sites showed chronic active colitis and multiple ill-defined, nonca-seating granulomas suggestive of CD. Tuberculosis was considered in the differential diagnosis. However, acid-fast bacilli stains and fluorescent mycobacterial stains on the biopsy specimens were negative. Purified protein derivative skin test showed less than 5 mm in duration. Mycobacterial polymerase chain reaction and culture from the biopsy tissues were negative. The patient was diagnosed with CD and was started on mesalamine 800 mg three times a day, which has been continued for the last 12 months. The patient was asymptomatic over this period.

In Asian-Indian populations, CD was considered almost nonexistent until 1986 (3); however, during recent years, CD is being reported from different parts of India. (1) Whether this increasing trend is due to improved diagnostic testing or changes in environmental conditions like improved sanitation is unknown. Psychological stress is a well-described risk factor for CD exacerbation, (4) and we believe that it played a role in our patient's presentation.

Since incidence of CD is on the rise in Asian-Indian populations, and it may present in an atypical manner, we recommend maintaining high index of suspicion for CD in Asian-Indian patients presenting with acute massive gastrointestinal hemorrhage.

Sagar U. Nigwekar, MD

Department of Internal Medicine

Rochester General Hospital

Rochester, NY

Kevin J. Casey, MD

Department of Gastroenterology

University of Rochester School of Medicine

Rochester General Hospital

Rochester, NY

References

1. Desai HG, Gupte PA. Increasing incidence of Crohn's disease in India: is it related to improved sanitation? Indian J Gastroenterol 2005;24:23-24.

2. Kostka R, Lukas M, Massive, life-threatening bleeding in Crohn's disease. Acta Chir Belg 2005;105:168-174.

3. Antia FP. Crohn's conundrum in Indians, Indian J Gastroenterol 1986;5:79-80.

4. Mardini HE, Kip KE, Wilson JW. Crohn's disease: a two-year prospective study of the association between psychological distress and disease activity. Dig Dis Sci 2004;49:492-497.