S2238 Crohn's Flare While Treating Tuberculosis Reactivation

INTRODUCTION: Crohn’s disease (CD) is an idiopathic inflammatory condition of the gut with relapsing-remitting nature. There is increasing evidence for the use of anti-TNF therapy early in the course of disease, but this comes with an increased risk of tuberculosis (TB) reactivation. We present a case of maintaining remission of CD while treating extrapulmonary TB. CASE DESCRIPTION/METHODS: A 25-year-old male with ileocolonic CD presented with shortness of breath, fever and productive cough. CD was diagnosed 2 years prior and complicated by anorectal fistula Previous treatment included prednisone and methotrexate (MTX) before escalating to infliximab. Upon presentation, CT scan of the chest revealed a large left pleural effusion with sputum AFB and pleural biopsy positive for mycobacterium tuberculosis (MTB). Of note the TB Quantiferon gold test prior to starting Infliximab was negative and infliximab was stopped upon TB diagnosis. During this admission there was increased drainage from the perianal fistula, requiring placement of a seton stitch. A colonoscopy and biopsy of the fistula excluded tuberculosis and was consistent with a Crohn’s flare. Prednisone 60 mg daily was started to achieve Crohn’s remission and he was discharged on RIPE therapy. While tapering steroids he developed increased drainage and was restarted on MTX. He responded well, with decreasing draining from the fistula and remained in remission while tapering off steroids and completing the initiation phase of TB treatment. He remains on continuation phase. DISCUSSION: Anti-TNF therapy brings hope for treating CD early in the disease course, but also increases the risk of TB. It is believed that TNF mediated signaling is impaired by these agents leading to an exacerbation of chronic infection associated with granuloma formation. Once reactivation occurs it is necessary to discontinue biologic agents and establish a new regimen for maintenance of CD. Glucocorticoids are rarely used in fistulizing CD and MTX can be considered with little data for perianal disease. There is no clear data to suggest the optimal agent to maintain remission during tuberculosis treatment. In a small population anti-tuberculous therapy may provide a benefit over placebo for the prevention of relapse in participants with CD. Our patient’s presentation is very rare and disease induction and remission was achieved with MTX. We believe MTX is a useful option in this special situation to navigate tuberculosis treatment safely.