A 49 year old male farmer has been bothered for years by a migratory arthralgia of the large joints. More recently, he's developed diarrhea, weight loss, abdominal pain, and severe wasting. His family has noted that he's been more confused as well. But most recently, he's developed a curious continuous rhythmic movement of eye convergence with concurrent contractions of the muscles of mastication. On exam, he has a vertical gaze palsy and a cerebellar ataxia. Labs rule out thyroid disease, connective tissue disease, inflammatory bowel disease, and HIV/AIDS. Labs show an elevated INR.
The patient undergoes endoscopy with small bowel biopsy, shown below.
Image shown under fair use.