SCIENTIFIC
Malakoplakia Associated with Colonic Adenocarcinoma : Case Report and Literature Review of a Rare Occurrence
AUTHORS : Sarah Tolaymat 1
Faryal Afridi , MD 2 Emily Groves MD 2
1
Medical Student , West Virginia University School of Medicine , Morgantown , WV
2
Department of Surgery , West Virginia University School of Medicine , Morgantown , WV
ABSTRACT
INTRODUCTION Malakoplakia is a rare granulomatous disease of possible infectious etiology . It is postulated to be triggered by bacteria that are associated with an altered immune response due to primary or secondary immunodeficiency . The disease is typically found in the urinary tract but has also been reported to occur in other bodily systems . Colonic malakoplakia is particularly rare , and it can occur in conjunction with , and mimic , colorectal carcinoma .
We describe the case of a 63-year-old female with a complicated medical history who presented with a bowel obstruction due to a large mass of unknown etiology at the ileocecal junction . An exploratory laparotomy revealed extensive local disease and peritoneal carcinomatosis . Pathology analysis revealed poorly differentiated adenocarcinoma with associated malakoplakia . A brief description and literature review of this rare diagnosis are provided .
CASE PRESENTATION
A minimally verbal 63-year-old female , accompanied by her caregiver , presented with complaints of abdominal pain and feeding intolerance . Along with having Crohn ’ s disease , the patient was a liver transplant recipient secondary to primary sclerosing cholangitis . Initially , her Crohn ’ s disease was controlled with mesalamine but was switched to tacrolimus and mycophenolate post-liver transplant . She had been on tacrolimus and mycophenolate for three years before presenting . She also had a history of seizure disorders associated with a traumatic brain injury ( TBI ). Due to the TBI and other conditions , she was fed through a gastrostomy tube . The patient underwent an abdominal computed tomography ( CT ) scan two weeks prior to presentation . At that point , she was diagnosed with a large right lower quadrant abdominal mass of unknown etiology and was scheduled for an outpatient colonoscopy ; however , before the procedure could be done , the patient presented with a bowel obstruction that required hospital admission and emergent surgical intervention . The intra-operative findings were significant for a large circumferential mass at the juncture of the terminal ileum and cecum . The mass extended around the femoral vessels , went into the pelvis and retroperitoneum , and invaded the pelvic sidewall . Additionally , scattered peritoneal deposits consistent with peritoneal carcinomatosis were observed . Giv- en the extent of the disease , a complete resection was deemed impossible . The surgeons performed tumor debulking , a right colectomy , resection of the invaded abdominal sidewall , and small bowel resection with end ileostomy . Post-operative histopathologic evaluation showed poorly differentiated adenocarcinoma with involvement of 18 / 23 lymph nodes , characteristic of pathologic stage T4N2 . Furthermore , signet-ring cell features and histiocytic proliferation with granular eosinophilic cytoplasm and small calcospherite bodies were seen . These bodies were best viewed using a von Kossa or Prussian blue stain ( Figure 1 ), which is consistent with Michaelis-Gutmann bodies found in malakoplakia ( Figures 2-3 ). The patient had a return of bowel func-
FIGURE 1
FIGURE 2 FIGURE 3
H & E stain of patient ’ s proximal colon showing eosinophilic cytoplasm .
Black arrows indicate Michaelis- Gutmann bodies , filled with calcified and incompletely digested debris .
Signet ring cells found on pathology of patient ’ s proximal colon .
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