Elvira Delgado

Pneumocystis jiroveci (carinii) pneumonia following a second infusion of infliximab in a patient with ulcerative colitis

To the Editor: The anti–tumor necrosis factor– (TNF ) antibody infliximab is an effective therapy for patients with moderately severe ulcerative colitis who fail to respond to conventional therapy.1 Adverse effects related to infection are a major concern with the use of infliximab. Pneumocystis jiroveci (carinii) pneumonia is an uncommonly reported complication of infliximab-treated patients with inflammatory bowel disease. There have been a few case reports of Pneumocystis pneumonia occurring during infliximab therapy for Crohn’s disease.2–6 This is the first report of Pneumocystis pneumonia complicating therapy of infliximab in a patient with ulcerative colitis. A 45-year-old man with ulcerative colitis was admitted to the hospital in June 2006 because of a moderately severe exacerbation of ulcerative colitis. He had been taking corticosteroids and azathioprine since the initial diagnosis of the disease, which was established elsewhere in 2005. Treatment at the time of admission included azathioprine 100 mg/day, prednisone 16 mg/day, and mesalazine 3 g/day. He received 1 infusion of infliximab (Remicade, ScheringPlough, Madrid, Spain) 5 mg/kg intravenously, followed by a second infusion 15 days later. HIV, HBV, and HCV serologies were negative before infliximab therapy. Tuberculin skin testing was also negative. A positive clinical response was seen after the initial administration. However, 1 week after the second infusion of infliximab, he was admitted to the hospital because of fever of 39°C, fatigue, and headache. The white blood cell count was 3800/mm, the lymphocyte count 1300/mm, hemoglobin 10.7 g/dL, hematocrit 30.3%, serum albumin 2.5 g/dL, and C-reactive protein level 47 mg/L. Physical examination was unrevealing, but the chest X-ray showed a right basal infiltrate consistent with pneumonia. After discontinuation of azathioprine and reduction of the dose of prednisone to 8 mg/ day, intravenous empiric antibiotics was started (imipenem 500 mg every 6 hours, ciprofloxacin 400 mg every 12 hours, and metronidazole 500 mg every 8 hours). He did not improve during the next 48 hours and was admitted to the intensive care unit because of severe respiratory failure, with arterial oxygen saturation 85% despite 3 L/min oxygen therapy. Chest X-ray findings deteriorated (Fig. 1). Treatment with intravenous trimethoprim-salfamethoxazole (1600 mg every 8 hours) was started based on clinical suspicion of opportunistic infection caused by Pneumocystis jiroveci. Bronchoscopy with bronchoalveolar lavage confirmed the presence of P. jiroveci. The CD4 lymphocyte count was 180 cells/mm. Intravenous trimethoprim-salfamethoxazole was given for 2 weeks, followed by oral therapy. Follow-up laboratory tests and chest Xray showed complete resolution. When last seen, in October 2007, he had no complaints, and nothing abnormal could be found on examination or chest radiographs. Given the temporal relationship between infliximab and the onset of symptoms, we suspected that TNF therapy was related to P. jiroveci infection. To our knowledge no previous cases of P. jiroveci pneumonia have been reported associated with the use of infliximab in patients with ulcerative colitis. In agreement with previous reports of Pneumocystis pneumonia complicating therapy of infliximab in patients with Crohn’s disease,2–5 there was concurrent immunosuppression with corticosteroids and/or azathioprine. Bronchoalveolar lavage must be rapidly performed in patients with inflammatory bowel disease presenting with fever, pulmonary infiltrates, lymphopenia, and hypoxemia. Pneumocystis pneumonia remains a serious cause of morbidity and mortality in immunocompromised

Combined Liver and Kidney Transplant in a Patient with Budd-Chiari Syndrome Secondary to Autosomal Dominant Polycystic Kidney Disease Associated with Polycystic Liver Disease: Report of a Case with a 9-Year Follow-Up

Polycystic liver disease (PLD) is a hereditary disease inherited by autosomal dominant trait that occurs as a frequent extrarenal manifestation of autosomal dominant polycystic kidney disease (ADPKD). We report a case of a 59-year-old woman diagnosed with ADPKD associated with PLD. End-stage chronic renal failure with a secondary Budd-Chiari syndrome developed during the patients clinical course. She underwent combined liver and kidney transplantation, with a successful response over a 9-year follow-up period.

Síndrome de Budd-Chiari secundario a pseudotumor inflamatorio hepático: seguimiento durante 10 años

Inflammatory pseudotumor (IPT) of the liver is a rare benign tumor of unknown origin, it has the appearance of a malignant tumor but has a benign histology and clinical course. We report a case of a 63-year-old man diagnosed of IPT of the liver and followed for 10 years. During the clinical course, he developed a secondary Budd-Chiari syndrome, with a successful response to a transjugular intrahepatic portosystemic shunt over a 5-year follow-up period.

Methotrexate Pneumonitis in Crohn's Disease: A Rare Case Report and Review of Literature

Methotrexate (MTX) is an analog of folic acid with ntiproliferative and immunomodulating effects.1 Low-dose TX therapy is a well-recognized treatment for various inflammaory diseases, including rheumatoid arthritis, psoriatic arthritis, soriasis, and inflammatory bowel disease.2 More than 20 years go, the clinical efficacy of MTX was also established for steroidependent Crohn’s disease (CD).3 Pulmonary toxicity is a rare ide effect of MTX, which clinically is characterized by the new nset of dyspnea, dry cough, and fever and usually presents adiologically as an acute interstitial pneumonitis.4 Pneumonitis s a serious and unpredictable adverse event of treatment with TX that may become life-threatening.5 Since the first description n 1969,6 Imokawa et al.7 collected 123 cases of MTX-induced neumonitis published in the English language literature and dded the description of 9 further cases. Cancer and leukemia ere the underlying diseases in most patients (64.4%) followed by soriasis (7.6%) and rheumatoid arthritis (6.1%). However, no case f pneumonitis associated with MTX therapy in patients with CD as identified in this clinical series. We here describe the case of woman with ileocecal CD who presented with pneumonitis after 0 months of treatment with MTX. In a review of the literature, we ere able to collect only three cases of MTX-induced pneumonitis n patients with CD,8–10 although one of these cases has been ublished twice.8,11 A review of salient clinical findings of CD atients with MTX-induced pneumonitis is also presented. A 79-year-woman was followed up at the Gastroenterology

Acromegalia y tumores asociados: ¿qué debemos saber los gastroenterólogos?

Acromegaly is a clinical syndrome caused by the excessive production of growth hormone. It is associated with high morbidity and significantly increased mortality, mainly due to cardiovascular and respiratory complications, and cancer. Mortality is reduced to that of the general population following successful treatment, in other words, when insulin-like growth factor (IGF-I) and growth hormone values return to normal levels. Not all tumours associated with this syndrome benefit from cost-effective early diagnosis programmes. An in-depth knowledge on the part of clinicians of the morbidity and mortality associated with acromegaly, allowing them in many cases to anticipate the expected clinical course of the disease, is the best therapeutic and follow-up strategy in these patients.