A 38-Year-Old Woman With Complicated and Steroid-Dependent Crohn's Disease

Authors: Shardul Nanavati, MD, Jim Schwartz, MDSeries Editor: Richard Goodgame, MD

Disclosures

July 25, 2003

Case Presentation

The patient is a 38-year-old woman who was referred by another gastroenterologist with a referral note as paraphrased below:

"This patient with a history of headaches and a possible diagnosis of multiple sclerosis (MS) also has a history of Crohn's disease since 1993. She underwent a proctocolectomy and ileostomy in 1997 and did well postoperatively. Near the end of 2000, she developed active ileal disease with ulcerations and increasing abdominal pain. She went into remission on steroids, which were tapered gradually over a period of about 6 months. The ileal disease recurred at the end of 2001. A steroid-induced remission was achieved, but steroids could not be tapered below 20 mg/day despite adequate doses of 6-mercaptopurine (6-MP) and various trials of oral budesonide and topical steroids and 5-aminosalicylic acid compounds. She develops right lower quadrant pain, diarrhea, and bleeding from the ileostomy each time she reduces the prednisone dose below 20 mg/day. The patient appears to be a candidate for infliximab therapy. There is concern regarding potential side effects."

The patient denied any fevers, chills, nausea, vomiting, or other gastrointestinal symptoms. She has a history of childhood epilepsy. Recently, she has had headaches, occasional paresthesias, and fatigue. She denies any weakness, diplopia, eye pain, dysphagia, sensory loss, or other neurologic symptoms.

Her past medical history is significant for Crohn's disease, as indicated in the referral note above. Over the last year, she has developed headaches and vague symptoms. A neurologist diagnosed "possible MS."

Her medications include 6-MP, 50 mg/day, and prednisone, 30 mg/day. She has no history of excessive alcohol or tobacco use, no substance abuse, no travel, and has stable family and finances. Family history is not significant.

Results of physical examination revealed normal vital signs. She was mildly obese. There were no enlarged lymph nodes or skin lesions. The head, ears, eyes, nose, and throat were normal. Cardiac and pulmonary examinations were normal. The abdominal exam showed postoperative changes. The ileostomy had inflamed mucosa with a tender indurated area palpable deep around the stoma. There was no rebound or guarding. The neurologic examination was normal.

Results of routine laboratory studies revealed the following: hemoglobin, 12 g/dL; white blood cell count, 8 x 103 cells/mm3 with normal differential count; platelets, 318 x 103/mm3; mean corpuscular volume, 91 fL; normal serum chemistries; total protein, 7.1 g/dL; and albumen, 3.9 g/dL. Blood levels of 6-thioguanine were in the therapeutic range and 6-methyl mercaptopurine was in the nontoxic range.

Ileoscopy was performed and multiple ulcerations were seen (Figure 1). An abdominal CT scan showed severe inflammation in the region of the terminal ileum and the ostomy (Figures 2 and 3).

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