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A 56-year-old man had multiple evaluations for diarrhea and was given various gastrointestinal diagnoses, including celiac disease, giardiasis, and enterocolonic fistula due to Crohn’s disease (see ). After empiric treatment with infliximab, he returned to the hospital with abdominal pain and anemia. Additional testing and imaging showed immunoglobulin A (IgA) and IgM deficiency, monoclonal gammopathy of unknown significance (MGUS), and signs of bowel ischemia.
Comment
Diagnoses must be revisited when a patient’s course does not progress as expected (e.g., worsening “Crohn’s disease” with infliximab). As the discussant points out, this patient’s MGUS can mask IgG deficiency — which, if present, along with deficiencies in IgA and IgM —…