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+A 50-year-old man, diagnosed with Crohn's disease with complex ileal and perianal involvement on immunosuppressant treatment, who came to the emergency department with fever, perianal suppuration and diarrhoea of 1 week's evolution. The patient had been on salicylates and azathioprine (2.5 mg/kg/day, adjusted according to TPMT levels) for 2 years and had received 6 doses of infliximab, a biological treatment that he discontinued 6 months before the current admission, for work-related reasons.
+On physical examination, the patient appeared in poor general condition, being febrile (39 ºC), hypotensive (BP 80/40 mmHg), tachycardic (104 bpm) and tachypneic (22 rpm). In the right iliac fossa there was a palpable "mass effect" of increased consistency and a fistulous orifice in the left buttock over an indurated, erythematous, hot and painful area. Urgent laboratory tests showed anaemia (Hb 7.9 g/dl, Hct 29%), renal failure (creatinine 4 mg/dl) and elevated acute phase reactants (CRP 127, platelets 424,000/ml). With the probable diagnosis of sepsis and multifactorial renal failure (salicylates, dehydration, etc.), treatment was started with serum therapy and broad-spectrum antibiotics. During the following 24 hours, the patient presented disorientation, agitation and deterioration of renal function with evident metabolic and hydroelectrolyte alterations (urea 68 mmol/l, creatinine 6.9 mg/dl, sodium 138 mmol/l, potassium 6 mmol/l, total calcium 7.5 mmol/l, inorganic phosphorus 5.1 mmol/l, LDH 17,481 U/l, urate 44 mg/dl). In view of these results, a renal Doppler ultrasound was performed, which was anodyne, and the renal failure was interpreted as multifactorial in origin, aggravated by the precipitation of uric acid crystals, for which treatment was started with hyperhydration, urine alkalinisation, haemodialysis, allopurinol and rasburicase, with a marked decrease in urate levels (urate 1.8 mg/dl). However, in view of the progressive clinical worsening of the patient's general condition, an abdominopelvic CT scan was performed, which showed a retroperitoneal mass measuring 13 x 10 cm and a lesion in the right flank measuring 15 x 8.6 cm, which appeared to correspond to a conglomerate of fixed loops with a thickened wall, without being able to rule out an underlying neoplasm. Multiple adenopathies in the mesenteric, iliac and inguinal chains were also observed, as well as a left perirectal lesion, probably related to his history of abscess and perianal fistula. The latter lesion was the only radiological finding observed, two months before the current episode, in an abdomino-pelvic MRI to monitor his perianal disease.
+Despite supportive treatment, the patient continued with fever, decreased level of consciousness, progressive dyspnoea and anuria, and died three days after admission to the ward. The definitive diagnosis was obtained after necropsy: plasmoblastic plasmacytoma with a predominance of lamda-type light chains infiltrating terminal ileum and cecum, root of the mesentery, abdominal lymph nodes and bone marrow.
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