Crohn disease or intestinal fistulising tuberculosis? Diagnosis difficulties in a case treated with infliximab and corticosteroids.

Crohn disease represents an idiopathic inflammatory bowel disorder with possibility of local and extra intestinal complications. Infliximab therapy is one of major therapeutic alternatives but this treatment may by followed by several possible infections, especially the reactivation of a latent tuberculosis. We present a case of a 28-year-old patient who was admitted in our hospital with clinical signs of bowel obstruction. Colonoscopy revealed close stenosis al the level of splenic flexure. Surgery was soon performed for the imminence of occlusion and pathology has revealed chronic inflammatory infiltrate with lymphocytes and plasma cells, interpreted as Crohn disease complicated with stenosis. A treatment with prednisone 30 mg/day, ciprofloxacin 1000 mg/day administrated intermittently and sulphasalasine 3 g/day for one year was indicated but the patient develop external abdominal fistula. Infliximab therapy 5 mg/kg/dose was administered at two weeks interval, with initial good results after two doses. At two weeks after the second dose, the patient has presented fever and weight loss; abdominal CT-scan has revealed inflammatory adherences of right flexure of the colon with external fistula, resolved by surgery. The evolution was later complicated by right tibio-tarsian involvement, which imposed orthopedic intervention. Pathology has revealed bone tuberculosis and antibacillary therapy was initiated with good results.

CONCLUSIONS

Bone tuberculosis may represent a rare evolutive modality at a patient with Crohn disease treated by Infliximab and corticoids. Infliximab therapy in a patient with immunosuppressant (previous corticotherapy, splenectomy) may activate a latent center of tuberculosis. Ciprofloxacin therapy may explain insidious modality of evolution by minor antibacillary effect.