Pigmented

A 48 year old man presents with episodic watery diarrhea for five months, which was predominantly nocturnal. He had also lost 8 kg of weight during the preceding year.

His medical history is unremarkable, and he is not on any drugs. There is no significant history of travel.

His serum albumin is found to be 2.5 g/dL (normal: 3.5 to 5.5 g/dL).

Select Relevant Investigations
Serum Electrolytes

Performed

Na+: 132 mEq/L (135 - 145)
K+: 3.4 mEq/L (3.5 - 5.5)
Cl-: 97 mEq/L (95 - 105)
Stool Analysis

Performed

No amoeba, ova or cysts identified
No pus cells or erythrocytes
Fecal fat analysis: 9 g/24h (normal: 2 - 6)
Bacterial and protozoal cultures: negative
Morning Cortisol

Performed

22 mcg/dl (<3: adrenal insufficiency; 3-19: indeterminate; 19-25: unambiguously normal)
Upper GI Endoscopy + Biopsy

Performed

The duodenal mucosa shows pale yellow shaggy areas alternating with erythematous regions. Biopsies reveal expanded villi containing macrophages which stain positive to the Periodic Acid-Schiff (PAS) stain.

Select Relevant Management
Antibiotics
Steroids
Surgical resection
Dietary restrictions