Transcript Journal Club

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