1. NYU Medical Grand Rounds Clinical Vignette Verity Schaye MD, PGY-2 February 3, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. A 51-year-old man presents for evaluation of an abnormal pre-operative chest X-ray. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 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.

4. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 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.

5. Additional History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Past Medical History Crohn’s disease Ankylosing spondylitis Past Surgical History Incision and drainage of perirectal abscesses Family History Mother – died after a stroke Social History Divorced Lives with children Former smoker Quit 10 years ago Denies alcohol use Denies illicit drug use

6. Outpatient Medications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Infliximab infusion every 8 weeks Mercaptopurine 75mg Daily Allergies: No known allergies

7. Physical Examination U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS General: Cachectic man in no acute distress Vitals: T 98.0F, BP 90/60, HR 100, RR 18 O 2 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.

8. Studies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 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)

9. Imaging Studies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 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

10. Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Reactivation tuberculosis in the setting of Crohn’s disease treated with immunomodulatory therapy

11. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 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.

12. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 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.

13. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Mycobacterium xenopi infection complicating treatment of refractory Crohn’s disease