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NYU Medical Grand Rounds Clinical Vignette Verity Schaye MD, PGY-2 February 3, 2010 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Chief Complaint A 51-year-old man presents for evaluation of an abnormal pre-operative chest X-ray. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History Past Medical History Family History • Crohn’s disease • Ankylosing spondylitis • Mother – died after a stroke Social History Past Surgical History • Incision and drainage of perirectal abscesses UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Divorced • Lives with children • Former smoker • Quit 10 years ago • Denies alcohol use • Denies illicit drug use Outpatient Medications Infliximab infusion every 8 weeks Mercaptopurine 75mg Daily Allergies: No known allergies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Studies • 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) UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Imaging Studies • 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 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnosis 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis Mycobacterium xenopi infection complicating treatment of refractory Crohn’s disease UNITED STATES DEPARTMENT OF VETERANS AFFAIRS