http://www.docguide.com/news/content.nsf/news/8525697700573E1885256DC70068A21F?OpenDocument&c=IBD&count=10 By Maggie Schwarz
BALTIMORE, MD -- October 22, 2003 -- A patient taking infliximab for severe fistulising Crohn's disease developed cryptococcal pneumonia requiring lung resection, it was reported here October 13th at the 68th Annual Scientific Meeting of the American College of Gastroenterology.
Matthew J. Hrnicek, MD, and Renee L. Young, MD, of the University of Nebraska Medical Center, Omaha, Nebraska, presented this case report.
Dr. Hrnicek noted that patients taking immunosuppressants like infliximab may be rendered about as immunodeficient as a typical AIDS patient, and are prone to opportunistic infections like tuberculosis and fungal infections. T1-cell-mediated immunity is required to clear a pulmonary cryptococcal infection.
The 51-year-old patient presented after a 5-day history of dry cough, fatigue, headache, fever and chills. He had recently returned from a deer hunting expedition. He received two separate doses of intravenous infliximab, 6 weeks and 4 weeks prior to presentation. His anti-inflammatory medications also included prednisone, methotrexate and ciprofloxacin.
His chest x-ray on admission showed a well-circumscribed right lower lung nodule. Laboratory examination revealed a mildly elevated serum white blood cell count with lyumphocytopenia. Bronchoalveolar lavage demonstrated budding yeast forms.
Treatment was begun with intravenous amphotericin B, vancomycin and piperacillin/taxobactam. Methotrexate was discontinued and prednisone decreased to 20 mg daily. Subsequently, he underwent right thoracotomy with excision of the right lower lung mass. Seven days postoperatively, Cryptococcus neoformans grew from a culture of the excised tissue. The previous antimicrobial regimen was discontinued in favor of intravenous fluconazole.
The severity of his Crohn's disease required continuation of infliximab therapy, but it was restarted along with oral fluconazole. Eight months after discharge, the patient is still taking both medications.
Dr. Hrnicek warned that patients taking immunomodulators like infliximab who develop fevers or chills need thorough examination for opportunistic infection. He noted that infliximab reduces endoscopic and histological Crohn's disease activity and improves quality of life in these patients. He suspects that there may be a subpopulation of infliximab recipients at risk for invasive fungal infections who might benefit from prophylactic antifungal therapy, as in the case he presented.
[Study title: Infliximab Therapy Predisposes Patients to Serious Opportunistic Infections.]