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CLINICAL IMAGE
Year : 2018  |  Volume : 148  |  Issue : 6  |  Page : 761-762

Comb sign in a patient with ankylosing spondylitis


Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.

Date of Submission02-Aug-2017
Date of Web Publication12-Feb-2019

Correspondence Address:
Hsiang-Cheng Chen
Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_1256_17

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How to cite this article:
Chen YH, Chen HC. Comb sign in a patient with ankylosing spondylitis. Indian J Med Res 2018;148:761-2

How to cite this URL:
Chen YH, Chen HC. Comb sign in a patient with ankylosing spondylitis. Indian J Med Res [serial online] 2018 [cited 2019 Mar 22];148:761-2. Available from: http://www.ijmr.org.in/text.asp?2018/148/6/761/252153

†Patient's consent obtained to publish clinical information and images.


A 24 yr old man presented to the department of Emergency, Tri-Service General Hospital, Taiwan, in December 2014 with acute right lower quadrant (RLQ) abdominal pain with fever for three days. He was diagnosed with ankylosing spondylitis (AS) one year ago and received celecoxib, sulphasalazine and methotrexate. Physical examination showed pale conjunctiva and RLQ abdominal tenderness with peritoneal sign. Laboratory assessments showed haemoglobin, 4.7 g/dl; white blood cell count, 8.98×103/μl; neutrophil, 64.4 per cent; lymphocyte, 27.5 per cent; platelet 474×103/μl; C-reactive protein, 2.2 mg/dl (normal range <0.5 mg/dl); erythrocyte sedimentation rate, 12 mm/h (normal range <15 mm/h); blood urea nitrogen, 11 mg/dl; creatinine, 0.6 mg/dl; and aspartate aminotransferase, 10 IU/l. The abdominal computed tomography (CT) scan demonstrated irregular wall thickening of the ascending colon with peripheral fatty stranding and multiple enlarged lymph nodes [Figure 1], and the comb sign over the right colon [Figure 2]; adenocarcinoma of the colon was suspected. Colonoscopy showed shallow ulcers and severe stricture more than 50 cm from the anal verge, and biopsy showed no malignant cell, suggesting Crohn's disease. The patient recovered after empirical antibiotics with flomoxef and methylprednisolone 80 mg for seven days.
Figure 1: Contrast-enhanced abdominal computed tomography scan showing irregular mural thickening and contrast enhancement of the mucosa of the ascending colon (arrow) with peripheral fatty stranding and multiple enlarged lymph nodes.

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Figure 2: Computed tomography scan in the coronal plane showing vascular dilatation, tortuosity and enlargement of the vasa recta on the mesenteric side of the ileum - the comb sign (arrow).

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The comb sign refers to a hypervascular appearance of the mesentery which can be seen in active Crohn's disease or other acute inflammatory conditions of bowel and lupus mesenteric vasculitis. Although it is not pathognomonic of Crohn's disease, in a known case of Crohn's disease, it would suggest that the disease was extensive, advanced and active. The present case suggests that Crohn's disease should be considered when an abdominal mass lesion in the RLQ abdomen with comb sign is observed with AS. However, biopsy should be done to exclude carcinoma of the colon which may co-exist with Crohn's disease.

Conflicts of Interest: None.




    Figures

  [Figure 1], [Figure 2]



 

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