1. CASE HISTORY #1 AIBD Breakout Session Douglas C. Wolf, M.D.

2. DISCLOSURES Speakers Bureau: AbbVie, Janssen, UCB Consultant: AbbVie, Janssen, UCB Research Support: AbbVie, Janssen, UCB

3.  35 yo female diagnosed in 1990 with Crohn’s disease  c/o lower abdominal pain and diarrhea  Crohn’s colitis treated with prednisone and 6-MP  Needed multiple courses of prednisone due to disease flares  3 Hospitalizations between 1990 and 2000  1998-2000, Recto-vaginal fistula treated unsuccessfully with 6-MP and antibiotics

4.  PR was referred for IBD specialist evaluation.  She was offered different treatment options including participation in the ACCENT II clinical trial.  She was randomized and rapidly gained benefit with fistula closure on infliximab vs. placebo in addition to 6-MP 50 mg a day  She completed the 54 week clinical trial in remission

5.  In 2001, she was continued on the same therapy: infliximab 5mg/kg q 8 weeks and 6-MP 50 mg/day  She remained asymptomatic with no abdominal pain, diarrhea, bleeding, or extraintestinal manifestations.  In 2006, she developed hip pain. She saw 3 orthopedists before an MRI was ordered and this showed a pelvic mass.  Biopsy revealed non-Hodgkin’s lymphoma.

6.  She was treated with rituximab based chemotherapy.  She responded and was disease free at 9 months.  In 2007, 6 months after completing chemotherapy, she developed slight fistula recurrence in the perianal area. What would you do ?

7.  Initially controlled with metronidazole, but developed neuropathy,  For the past 6 years has been Crohn’s disease and fistula free on rifaximin.

8.  She had no active fistula or other active Crohn’s disease during her chemotherapy.  She was monitored by her Emory hematologist for 5 years and remained disease free.  In 2012, her hematologist felt there was no need for further follow up  She sees me every 6 months