Recurrent Asymptomatic Sigmoid Diverticular Perforation in a Patient with Pemphigus Vulgaris on Immunosuppressive Therapy: A Case Report

Abstract

Patient: Male, 57 Final Diagnosis: Perforated diverticuli Symptoms: Asymptomatic Medication: — Clinical Procedure: — Specialty: Surgery Objective: Rare co-existance of disease or pathology Background: Perforation of the colon is associated with high mortality and requires early diagnosis. However, the diagnosis of perforation from atypical causes can be a diagnostic challenge. This report is of a rare case of recurrent sigmoid colonic perforation in a patient with diverticular disease who did not present with an acute abdomen but who had pemphigus vulgaris treated with immunosuppressive therapy. Case Report: A 57-year-old man with pemphigus vulgaris was treated with steroid s, non-steroidal anti-inflammatory drugs (NSAIDS), and azathioprine. He had episodes of abdominal bloating but denied any other symptoms. He was diagnosed with spontaneous sigmoid diverticular perforation without presenting with an acute abdomen. Conclusions: Diverticular perforation can be asymptomatic in patients on immunosuppressive therapy. Therefore, there should be a high index of suspicion for bowel perforation in patients with abdominal symptoms who are treated for skin diseases, such as pemphigus vulgaris, and are on steroids and other immunosuppressive treatments.

Silent Sigmoid Colon Diverticular Perforation: A Case Report

“…Classically, pneumoperitoneum secondary to bowel perforation presents with typical symptoms including fever, nausea, and severe abdominal pain, in addition to clinical signs of peritonitis on examination. In rare cases, pneumoperitoneum can present silently without clinical signs of illness; and such instances have been described in case reports [ 4 - 7 ]. Perforation of the colon is associated with high morbidity and mortality, and hence it requires early diagnosis.…”

“…An example of the association between silent pneumoperitoneum and corticosteroids/DMARDs was seen in the case of a 57-year-old male who had pemphigus vulgaris treated with immunosuppressive therapy of steroids and azathioprine; he had recurrent sigmoid colonic perforation but did not present with an acute abdomen. The authors concluded that both steroids and azathioprine's immunosuppressive effects may have completely obscured the peritonitis inflammatory signs, resulting in the absence of typical presenting symptoms [ 7 ].…”