P0608 - Disseminated Blastomycosis Following Initiation of Tumor Necrosis Factor Inhibitor Therapy for Crohn’s Disease

Samuel C. Purkey, DO¹, Mahmoud Shorman, MD^2
1University of Tennessee Medical Center, Knoxville, TN; ²University of Tennessee Graduate School of Medicine, Knoxville, TN

Introduction: It is standard of care to screen for mycobacterium tuberculosis (TB), hepatitis B (HBV), and hepatitis C (HCV) prior to initiation of tumor necrosis factor-alpha (TNF) inhibitor therapy. Consideration for screening endemic fungal species may be justified. We present a case of disseminated blastomycosis following initiation of adalimumab therapy for Crohn's disease (CD).

Case Description/Methods: We present a 29-year-old female presenting to gastroenterology clinic for evaluation of a thickened terminal ileum (TI) on computed tomographic (CT) imaging. She confirmed abdominal pain, constipation, hematochezia, and a 15-pound weight loss over the past year. Her family history was significant for inflammatory bowel disease (IBD). Magnetic resonance enterography revealed findings consistent with Crohn's disease. She subsequently underwent a colonoscopy revealing scattered ulcers and strictures in the TI. Biopsies revealed active ileitis consistent with CD. She was started on a prednisone taper and transitioned to maintenance therapy with adalimumab following a negative hepatitis panel and interferon-γ release assay. On repeat CT, she had ileal improvement but a new 11mm right pulmonary nodule with numerous splenic and hepatic hypodensities. She was referred to infectious disease for further evaluation revealing a positive Blastomyces urine antigen, suggesting disseminated blastomycosis. Her adalimumab was held for 1 month with initiation of itraconazole. She now remains on adalimumab while completing blastomycosis treatment with 1 year of itraconazole.

Discussion: TNF inhibitors are an evolving class of medications helping relieve patients suffering from an array of disease processes, including IBD. While biologic therapies target key components of a dysregulated immune system to treat autoimmune or systemic inflammatory diseases, their alteration to the immune system also places patients at increased risk for opportunistic and endemic infections. The standard of care to screen patients for TB, HBV, and HCV prior to initiation of biologic therapy is long-standing. However, as more patients are initiated on these medications, it is important for physicians to remember endemic infections and consider pre-initiation screening based on risk factors and geographic location. With this case, we raise the question of whether endemic fungal infection screening should be standard of care for pre-initiation screening, as these can propagate life-threatening infections.


Figure: A. MR enterography revealing wall thickening and mucosal hyperenhancement of the terminal ileum consistent with Crohn's disease with an inflammatory stricture involving the terminal ileum over a length of about 3 cm.
B. Initial CT scan of the abdomen and pelvis with IV contrast revealing a normal liver and spleen.
C. Repeat CT scan of the abdomen and pelvis with IV contrast revealing numerous new subtle punctate left and right hepatic hypodensities concerning for infectious etiology.


Disclosures:
Samuel Purkey indicated no relevant financial relationships.
Mahmoud Shorman indicated no relevant financial relationships.


Samuel C. Purkey, DO¹, Mahmoud Shorman, MD². P0608 - Disseminated Blastomycosis Following Initiation of Tumor Necrosis Factor Inhibitor Therapy for Crohn’s Disease, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.