Introduction: Biologic therapies have revolutionized the treatment of patients with inflammatory bowel disease (IBD) and Anti-TNFa inhibitors are the most commonly used agents for patients with moderate to severe disease. Prior to initiation, patients are checked for Tuberculosis (TB) and Hep-B but checking for other latent infections is determined by the Physician. Strongyloides, an endemic South American parasite, is one such potentially latent infection for which no guidelines exist. We present the multi-admission hospital course of a patient with severe Crohn’s Colitis who had reactivation of latent strongyloides after starting Infliximab.
Case Description/Methods: A 53 year old Male from South America presented to the ED with hematochezia, fevers, abdominal pain, and a purulent left shin lesion. Past medical history included poorly controlled Crohn’s Colitis refractory to other therapies. Upon arrival the patient was tachycardic, had diffuse abdominal pain, and had multiple bloody bowel movements. A 7 by 4 cm ulcerated lesion with visible necrotic tissue, fibrinous debris and violaceous borders was visualized on his leg. Blood work revealed leukopenia, anemia, an elevated CRP and ESR. Biopsy of the lesion was consistent with Pyoderma Gangrenosum. He was treated with IV corticosteroids with improvement. Serologies for Hepatitis B, C, HIV, latent TB, and a stool test for parasites were negative. Given disease severity therapy with infliximab and 6-mercaptopurine (6MP) was started. The next day he developed worsening pain, and bloody diarrhea. Strongyloides parasites were visible in stool smears and blood work showed eosinophilia. Inflixmab and 6MP were discontinued and ivermectin and a steroid taper were started. Repeat stool studies revealed successful eradication of Strongyloides after which infliximab and 6MP were restarted. The patient had an uncomplicated discharge and is tolerating infliximab well.
Discussion: Biologics are becoming very common in the medical field in the setting of an increasingly interconnected world and this case shows positive and negative aspects of this. While they may carry an increased risk of severe infection, they are well tolerated and provide dramatic relief. While screening may capture many latent infections there are no recommendations outside of Hep-B and TB. Developing new tools to screen or looking to our International Colleagues for guidance may be necessary as our communities at home become truly international.
