A 23-year-old man presented for evaluation of fevers and abdominal pain. He was well until 3 months prior to presentation, when he noted severe rectal pain and blood on his stool. Anoscopy showed a posterior midline anal fissure. Over the following month, he developed fever, for which he took ibuprofen, and he experienced a 20-pound weight loss. He was hospitalized at another institution for evaluation. Laboratory tests were remarkable for iron deficiency anemia, elevated inflammatory markers (eryth-rocyte sedimentation rate [ESR] and C-reactive protein [CRP]), and hypoalbuminemia. Stool studies were negative except for the presence of blood in stool specimens. Blood cultures, computed tomography (CT) of the chest/abdomen/pelvis (using intravenous contrast), and upper gastrointestinal series were normal. A colonoscopy to the cecum revealed a posterior anal fissure and a rectal ulcer. Random biopsies throughout the colon were normal, and biopsies of the rectal ulcer were consistent with ulceration but no inflammation. He was placed on iron supplementation and discharged.
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