NYU Medical Grand Rounds Clinical Vignette

Verity Schaye MD, PGY-2

February 3, 2010

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

A 51-year-old man presents for evaluation of an abnormal pre-operative chest X-ray.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was in his usual state of health until twenty years prior to presentation when he was diagnosed with Crohn’s disease.

• The patient’s disease course was complicated by the development of perirectal abscesses and fistulas that eventually were controlled with mercaptopurine.

• Three years prior to presentation the patient noted recurrence of the fistulas, and the patient was started on infliximab with good response.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient’s disease was stable on infliximab until 2 months prior to presentation, when he developed a perirectal abscess.

• During pre-operative evaluation for surgical drainage, a left upper lobe soft tissue opacity was seen on a routine chest x-ray.

Additional History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Past Medical History• Crohn’s disease• Ankylosing spondylitis

Past Surgical History• Incision and drainage of perirectal abscesses

Family History• Mother – died after a stroke

Social History• Divorced• Lives with children• Former smoker

• Quit 10 years ago• Denies alcohol use• Denies illicit drug use

Outpatient Medications

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Infliximab infusion every 8 weeks

Mercaptopurine 75mg Daily

Allergies: No known allergies

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

General: Cachectic man in no acute distress

Vitals: T 98.0F, BP 90/60, HR 100, RR 18

O2 saturation: 97% on room air

Abdomen: Multiple well-healed scars

Rectal: Tenderness noted at the 5 o’clock position, and evidence of prior healed fistulas

The remainder of the physical exam was normal.

Studies

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• CBC: Within normal limits

• Basic Metabolic Panel: Within normal limits

• Hepatic Panel: Within normal limits

• CRP: 1.54 mg/dL (0-0.5 mg/dL)

• ESR: 50 mm/60min (0-15 mm/60min)

Imaging Studies

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Chest X-Ray• Left upper lobe tissue opacity with an air-filled cavity which demonstrates a soft tissue mass

• CT of Chest• Cavitary lesion of the left apex most consistent with reactivation tuberculosis in the setting of this patient with evidence of left upper lobe scarring

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Reactivation tuberculosis in the setting of Crohn’s disease treated with

immunomodulatory therapy

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Clinical Course

• The patient was admitted to the hospital under respiratory isolation for further assessment.

• The patient’s Crohn’s disease therapy was held.

• Sputum AFB smears were obtained and negative.

• Bronchoscopy was performed and cultures obtained eventually grew Mycobacterium xenopi.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Clinical Course

• Rifabutin, ethambutol and clarithromycin were started in an effort to treat his infection and eventually restart his immunomodulating therapy.

• The patient did not tolerate treatment and the mycobacterial infection was incompletely treated.

• Due to the severe nature of his disease, mercaptopurine was eventually restarted with close follow-up of his pulmonary disease.

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Mycobacterium xenopi infection complicating treatment of refractory

Crohn’s disease