Cough and fever in a female with Crohn's disease receiving infliximab

Prophylaxis for Pneumocystis jirovecii pneumonia in patients with inflammatory bowel disease: A systematic review

Patients with inflammatory bowel disease (IBD) are at increased risk of developing Pneumocystis jirovecii pneumonia (PJP) than the general population. Many medications utilized for the treatment of IBD affect the immune system, potentially further increasing the risk of PJP. Recommendations for prophylaxis against PJP in this patient population are based upon limited evidence, and risk factors for PJP development are not well-agreed upon. The purpose of this systematic review was to consolidate and evaluate the evidence for PJP prophylaxis in patients with IBD. An electronic literature search was performed, and 29 studies were included in the review, of which 24 were case reports or case series. Combined data from five cohort studies showed an absolute risk of developing PJP to be 0.07%. The majority of patients who developed PJP were receiving corticosteroids at the time of diagnosis (76%). The number of concomitant immunosuppressants received at time of PJP diagnosis varied from one to four. All studies reporting treatment of PJP utilized sulfamethoxazole-trimethoprim. Of the 27 studies reporting mortality data, 19% of patients died. Given the lack of conclusive data regarding risk factors for PJP development and the overall low incidence of PJP in patients with IBD, it is recommended to assess the patient's risk on a case-by-case basis to determine whether PJP prophylaxis is warranted.

Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature Review

Immunosuppressive therapy is a known risk factor for opportunistic infections. We report the first case of severe Pneumocystis jirovecii infection requiring intensive care in a pediatric patient with inflammatory bowel disease (IBD). The literature was reviewed and there were 92 reported cases of Pneumocystis pneumonia (PCP) in patients with IBD. Most sources were case reports and there was likely reporting bias toward patients receiving immunomodulators, anti-tumor necrosis factor (anti-TNF) therapy, and those who died. Overall, 56% of patients were males and 58% had Crohn's disease. The median age was 45 years (interquartile range 30-68, range 8-78) and 86% of patients were lymphopenic. The case-fatality rate was 23%. Corticosteroids were used as IBD treatment in 88% of patients who subsequently developed PCP, 42% received thiopurines, 44% used anti-TNF therapy, and 15% received either cyclosporine or tacrolimus. Rates of mono, dual, triple, and quadruple immunosuppression therapy were 35, 35, 29, and 2%, respectively. This report highlights the importance of considering PCP in immunosuppressed lymphopenic pediatric IBD patients who present with unusual symptoms. Moreover, it should give gastroenterologists the impetus to limit immunosuppressive therapy to its minimal effective dose and consider options such as exclusive enteral nutrition wherever possible. Although there is no place for global PCP prophylaxis in IBD given the low incidence, in an era when there is increasing use of biologic agents with combination immunosuppressive therapy, the risk-benefit profile of PCP chemoprophylaxis should be revisited in selected cohorts such as patients on triple immunosuppression with corticosteroids, thiopurines, and a biological agent or calcineurin inhibitor, especially in lymphopenic individuals.

Increased dosage of infliximab is a potential cause of Pneumocystis carinii pneumonia

Methods

Pneumocystis carinii pneumonia occasionally appears in immunodeficient patients. While several reports have shown that Pneumocystis carinii pneumonia occurred in the early phase of starting infliximab treatment in patients with Crohn’s disease (CD), the present case suggests for the first time that an increased dosage of infliximab may also lead to pneumonia.

Results

A 51-year-old male had been taking 5 mg of infliximab for the treatment of CD for 10 years with no adverse events. Beginning in September 2013, the dose of infliximab had to be increased to 10 mg/kg because his status worsened. Thereafter, he complained of a fever and cough, and a CT scan revealed ground-glass opacities in the lower lobes of the bilateral lung with a crazy-paving pattern. Bronchoscopy detected swelling of the tracheal mucosa with obvious dilations of the vessels. A polymerase chain reaction using a bronchoalveolar lavage fluid sample detected specific sequences for Pneumocystis jirovecii; thus he was diagnosed with Pneumocystis carinii (jirovecii) pneumonia. After discontinuing infliximab and starting antibiotic treatment, his symptoms and CT findings were dramatically improved.

Conclusions

The administration of an increased dosage of infliximab can cause Pneumocystis carinii pneumonia in CD patients.

Nocardia infections among immunomodulated inflammatory bowel disease patients: A review

Human nocardiosis, caused by Nocardia spp., an ubiquitous soil-borne bacteria, is a rare granulomatous disease close related to immune dysfunctions. Clinically can occur as an acute life-threatening disease, with lung, brain and skin being commonly affected. The infection was classically diagnosed in HIV infected persons, organ transplanted recipients and long term corticosteroid treated patients. Currently the widespread use of immunomodulators and immunossupressors in the treatment of inflammatory diseases changed this scenario. Our purpose is to review all published cases of nocardiosis in immunomodulated patients due to inflammatory diseases and describe clinical and laboratory findings. We reviewed the literature concerning human cases of nocardiosis published between 1980 and 2014 in peer reviewed journals. Eleven cases of nocardiosis associated with anti-tumor necrosis factor (TNF) prescription (9 related with infliximab and 2 with adalimumab) were identified; 7 patients had inflammatory bowel disease (IBD), 4 had rheumatological conditions; nocardia infection presented as cutaneous involvement in 3 patients, lung disease in 4 patients, hepatic in one and disseminated disease in 3 patients. From the 10 cases described in IBD patients 7 were associated with anti-TNF and 3 with steroids and azathioprine. In conclusion, nocardiosis requires high levels of clinical suspicion and experience of laboratory staff, in order to establish a timely diagnosis and by doing so avoid worst outcomes. Treatment for long periods tailored by the susceptibility of the isolated species whenever possible is essential. The safety of restarting immunomodulators or anti-TNF after the disease or the value of prophylaxis with cotrimoxazole is still debated.

Pulmonary manifestations of inflammatory bowel disease

Extraintestinal manifestations of inflammatory bowel disease (IBD) are a systemic illness that may affect up to half of all patients. Among the extraintestinal manifestations of IBD, those involving the lungs are relatively rare and often overlooked. However, there is a wide array of such manifestations, spanning from airway disease to lung parenchymal disease, thromboembolic disease, pleural disease, enteric-pulmonary fistulas, pulmonary function test abnormalities, and adverse drug reactions. The spectrum of IBD manifestations in the chest is broad, and the manifestations may mimic other diseases. Although infrequent, physicians dealing with IBD must be aware of these conditions, which are sometimes life-threatening, to avoid further health impairment of the patients and to alleviate their symptoms by prompt recognition and treatment. Knowledge of these manifestations in conjunction with pertinent clinical data is essential for establishing the correct diagnosis and treatment. The treatment of IBD-related respiratory disorders depends on the specific pattern of involvement, and in most patients, steroids are required in the initial management. Corticosteroids, both systemic and aerosolized, are the mainstay therapeutic approach, while antibiotics must also be administered in the case of infectious and suppurative processes, whose sequelae sometimes require surgical intervention.

Pulmonary manifestations of Crohn’s disease

Crohn’s disease (CD) is a systemic illness with a constellation of extraintestinal manifestations affecting various organs. Of these extraintestinal manifestations of CD, those involving the lung are relatively rare. However, there is a wide array of lung manifestations, ranging from subclinical alterations, airway diseases and lung parenchymal diseases to pleural diseases and drug-related diseases. The most frequent manifestation is bronchial inflammation and suppuration with or without bronchiectasis. Bronchoalveolar lavage findings show an increased percentage of neutrophils. Drug-related pulmonary abnormalities include disorders which are directly induced by sulfasalazine, mesalamine and methotrexate, and opportunistic lung infections due to immunosuppressive treatment. In most patients, the development of pulmonary disease parallels that of intestinal disease activity. Although infrequent, clinicians dealing with CD must be aware of these, sometimes life-threatening, conditions to avoid further impairment of health status and to alleviate patient symptoms by prompt recognition and treatment. The treatment of CD-related respiratory disorders depends on the specific pattern of involvement, and in most patients, steroids are required in the initial management.

Perianal fistulae in Crohn's Disease: current and future approaches to treatment

: affecting sphincter integrity and continence. Traditional surgical and medical approaches are not without their limitations and may result in either comorbidity, such as fecal incontinence, or incomplete healing of the fistulae. Over the last 2 decades these limitations have led to a paradigm shift toward the use of biomaterials, and more recently cell-based therapies, which have met with variable degrees of success. This review discusses the traditional and current methods of treatment, as well as emerging and possible alternative approaches that may improve fistula healing.

[Non tuberculous anti-TNF associated opportunistic infections]

Anti-TNFalpha agents have revolutionized the treatment of patients with rheumatoid arthritis, spondylarthropathies and Crohn's disease. However, their use is associated with an increased risk of infections. Pyogenic infections (involving the lungs, skin and urinary tract) and tuberculosis are the more commonly observed infectious complications in patients receiving anti-TNFalpha agents. However, opportunistic infections have been increasingly reported in anti-TNFalpha-treated patients, and include non tuberculous mycobacteria, fungi (Pneumocystis jiroveci, Candida sp, Aspergillus, Cryptococcus, Histoplasma), opportunistic bacterial (Nocardia), parasitic (Leishmania) and viral (e.g. Cytomegalovirus, human herpes virus 8 [HHV 8]) infections. These infectious complications usually occur within the first months of therapy and are important causes of morbidity and mortality in anti-TNFalpha-treated patients. It is recommended to rule out infections, especially latent or active tuberculosis, before the initiation of anti-TNFalpha therapy. However, it is necessary to follow-up closely these patients to detect the possible occurrence of opportunistic infections.

Current understanding of Pneumocystis immunology

Pneumocystis jirovecii is the opportunistic fungal organism that causes Pneumocystis pneumonia (PCP) in humans. Similar to other opportunistic pathogens, Pneumocystis causes disease in individuals who are immunocompromised, particularly those infected with HIV. PCP remains the most common opportunistic infection in patients with AIDS. Incidence has decreased greatly with the advent of HAART. However, an increase in the non-HIV immunocompromised population, noncompliance with current treatments, emergence of drug-resistant strains and rise in HIV(+) cases in developing countries makes Pneumocystis a pathogen of continued interest and a public health threat. A great deal of research interest has addressed therapeutic interventions to boost waning immunity in the host to prevent or treat PCP. This article focuses on research conducted during the previous 5 years regarding the host immune response to Pneumocystis, including innate, cell-mediated and humoral immunity, and associated immunotherapies tested against PCP.

[Opportunistic co-infection in a patient with Crohn's disease during infliximab (anti-TNFalpha) therapy]

BACKGROUND

The biological therapies for chronic inflammatory diseases of autoimmune origin, particularly drugs inhibiting cytokines, such as the antagonists of the tumoral necrosis factor alpha (TNFalpha), are acceptably well tolerated in patients suffering rheumatologic, dermatologic and gastrointestinal pathologies. Nevertheless, pharmacologic vigilance studies have clarified several aspects of their security in daily clinical use. The adverse effects associated with inhibitors of TNFalpha can be related to the target (or class) and to the agent. The adverse effects related to the target include those potentially attributable to the inherent immunosuppressive state due to the blockade of the main cytokine, phenomenon that could increase the susceptibility to the infections and cancer.

AIMS

To expound the potential risk of serious infections, opportunistic or not, inherent to the use of biological therapies and, specifically, antagonistic drugs of TNFalpha, from the description of a case of invasive fungal infection.

METHODS

Revision of clinical records, obtained from the chronic inflammatory disease of autoimmune origin patient database, candidates or recipients of the new biological therapies, and study of the microbiological isolates.

RESULTS

A case of dual opportunistic infection (nocardiosis and aspergillosis) with a difficult diagnosis and complex management in an immunosupressed patient with Crohn's disease, triggered off after the administration of infliximab (monoclonal antibody anti-TNFalpha) is presented.

CONCLUSIONS

Invasive fungal infections, with isolated or associated clinical presentation to other opportunistic infections, are emerging in new groups-at-risk as they are the recipients of anti-cytokine biological therapies, regulators of inflammation and immunity. They can be potentially serious in their evolution and a high index of suspicion is needed sometimes for their prompt diagnosis. Possible preventive measures in patients with a high risk of suffering them will have to be investigated.

Pneumonia due to Nocardia cyriacigeorgica in a patient with Crohn's disease treated with infliximab

Infliximab, an anti-tumor necrosis factor α (TNF-α) antibody, is useful in the treatment of rheumatoid arthritis, Crohn's disease etc. It has been related to increases in the rate of several infections. We present the case of a 53-year-old woman diagnosed with community-acquired pneumonia due to Nocardia cyriacigeorgica who was taking infliximab, azathioprine and prednisone for Crohn's disease.