Patient's Relapsing IBD Prompts Closer Look at Her Prior Flares

Arthur M. Barrie III, MD, PhD

Disclosures

August 11, 2016

Clinical Presentation

A 38-year-old female established patient with long-standing remitting and relapsing moderately severe Crohn's colitis calls your office complaining of an acute flare-up of her inflammatory bowel disease (IBD).

Her chief complaint is diarrhea, as she reports having four to five loose-to-watery, nonbloody bowel movements per day with urgency. She is not experiencing any nocturnal diarrhea, leakage, or incontinence. Her diarrhea is associated with mild crampy abdominal discomfort, but she does not have fevers or any other extraintestinal manifestations.

Her diarrhea flare began 7 days ago without any obvious precipitating factor, as the patient denies preceding antibiotic exposure, unusual ingestions of food or drink, outdoor water exposure, travel, or sick contacts including pets. The patient is married and has three children ranging in age from 7 to 12 years, none of whom attend daycare. She is employed as a secretary at a local law firm. She has not recently visited any loved ones in a hospital or nursing home.

The patient is currently being treated with adalimumab, which was escalated to weekly injections 1 year ago owing to persistent mucosal disease observed on surveillance colonoscopy. The patient denies missing any injections prior to her current flare and takes no other medications, including nonsteroidal anti-inflammatory drugs. She was diagnosed with Crohn's colitis 13 years ago and was initially treated with oral mesalamine that proved ineffective. She was subsequently treated with 6-mercaptopurine, which she did not tolerate, followed by infliximab, which caused severe infusion reactions.

The patient's chronic disease has been aggravated by ongoing tobacco abuse despite multiple attempts to quit.

The patient's last flare was 8 months ago, at which time she was diagnosed with Clostridium difficile infection (CDI), her first such occurrence, which was preceded by antibiotic treatment for bronchitis. Her CDI was successfully treated with a 10-day course of oral vancomycin, and she has been in clinical remission up to now.

Prior flares have responded to corticosteroid therapy, as the patient has been prescribed numerous courses of prednisone since her diagnosis. Accordingly, based on her experience, the patient is requesting another round of prednisone to treat her current flare.

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