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Antonio Tursi, Alfredo Papa, Michele Maiorano, Onset of severe perianal disease in Crohn's disease under treatment with infliximab: Successful treatment with adalimumab and setons drainage, Inflammatory Bowel Diseases, Volume 17, Issue 2, 1 February 2011, Pages 676–678, https://doi.org/10.1002/ibd.21292
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To the Editor:
Tumor necrosis factor α (TNF-α) is a key proinflammatory cytokine involved in the pathogenesis of inflammatory bowel disease (IBD),1 as shown by using infliximab, a chimeric anti-TNF-α monoclonal antibody, in treating patients affected by severe IBD.2
Flare or onset of IBD in association with immunosuppression has been reported in the literature,3,–6 and flare of IBD under treatment with anti-TNF-α antibodies due to loss of response may occur.7
Here we present the case of an 18-year-old female patient with a diagnosis of ileal nonstricturing-nonpenetrating Crohn's disease (CD) since 2006. In August 2006 she experienced diarrhea, abdominal pain, and weight loss (10 kg in 3 months); a gastroscopy showed erosions of the second duodenal portion and a colonoscopy showed aphtoid ulcers in the terminal ileum. Histological examination of the specimens was compatible with active ileal CD. Magnetic resonance imaging (MRI) showed a slight wall thickening of the middle jejunum and of the terminal ileum for an extension of 15 cm in both locations (Fig. 1). Systemic treatment with steroids (budesonide and prednisone) was started, with poor success. In November 2006, due to chronically active CD, the patients started immunosuppressive treatment (azathioprine 2.5 mg/kg/day) and biologic treatment with infliximab 5 mg/kg i.v. for induction and maintaining treatment. She responded immediately to this treatment, recovered the weight, and was in remission for about 11 months. In October 2007, 7 days after the last infliximab infusion, the patient was referred for fever (up to 39°C), abdominal pain, and diarrhea with pus through the anus. After immediate cessation of azathioprine she was referred to an IBD Centre. Laboratory tests showed increased C-reactive protein (25.1 mg/dL), erythrocyte sedimentation rate (86 mm/h), and platelet count (470,000). A colonoscopy showed a canal anal substenosis and cobblestone aspect with serpiginous ulcers in the rectosigmoid region. MRI showed wall thickening of the rectum-sigmoid region for an extension of 20 cm, diffuse inflammation of the perianal region, and the presence of three perianal abscesses with three extrasphincteric fistulas (Fig. 2). These last features were also confirmed by an endoanal ultrasonography (EAU).
