New York Presbyterian-Weill Cornell Medical Center New York, NY, United States
Aiya Aboubakr, MD1, Waseem Ahmed, MD2, Fabrizio Michelassi, MD1, Ole Vielemeyer, MD3, Rhonday Yantiss, MD3, Carlos Retally, MD4, Dana J. Lukin, MD, PhD2 1New York Presbyterian-Weill Cornell Medical Center, New York, NY; 2Jill Roberts Center for Inflammatory Bowel Disease, Weill Cornell Medical College, New York, NY; 3New York-Presbyterian/Weill Cornell Medical Center, New York, NY; 4Pacífica Salud Hospital Punta Pacífica, Panama City, Panama, Panama
Introduction: Histoplasmosis is a fungal infection endemic to parts of North, Central and South America. Its clinical presentation is variable – most individuals are asymptomatic, but immunocompromised hosts can develop disseminated histoplasmosis (DH) with GI or skin involvement. The latter has been described with immunosuppressants including tumor necrosis factor (TNF)-α inhibitor therapy, commonly used for treatment of inflammatory bowel disease (IBD. Diagnosing DH in IBD is challenging due to similarity in presenting symptoms, and treatment with immunosuppressive medications can have devastating consequence.
Case Description/Methods: A 19-year old female from Panama with a history of ileocolonic, stricturing Crohn’s disease diagnosed at age 12 presented with progressive post-prandial abdominal pain and weight loss. She had no fevers or new rashes, but did note recent episodes of nocturnal diaphoresis. Her disease had been well-managed for seven years with adalimumab weekly, with addition of twice-daily weight-based azathioprine in the past year. CT scan of the abdomen and pelvis showed an 8-inch segment of stricturing and sclerosing ileitis. Escalation of therapy including a course of prednisone 40 mg daily failed to improve symptoms, and she ultimately underwent laparoscopic ileocecetomy. Pre-operative laboratory evaluation was notable for: WBC 2.56, Hgb 10.4, CRP 4.3, ESR 36. Extensive bowel ulceration and a “lead-pipe” ileum were visualized intra-operatively. Biopsies of the terminal ileum and cecum were notable for chronic active enterocolitis with extensive ulcers and poorly formed granulomatous inflammation, as well as fungi and granulomatous lymphadenitis consistent with histoplasmosis. There was no evidence of respiratory or cutaneous histoplasmosis on imaging and examination, and blood cultures were negative. HIV was excluded. Biologics were held and the patient was started on a one year course of itraconazole.
Discussion: Disseminated histoplasmosis occurs in immunocompromised patients, including those treated with anti-TNF therapy. It is important to consider DH in IBD patients on anti-TNF or combination therapy who present with abdominal pain non-responsive to escalation in therapy, as it may mimic IBD exacerbation, and further disseminate with immunosuppression. Furthermore, as in this case, the origin of stricturing disease may be multifactorial, and a surgical approach followed by antifungal therapy may be needed prior to resuming immunosuppressive therapy for underlying Crohn’s disease.
Disclosures: Aiya Aboubakr indicated no relevant financial relationships. Waseem Ahmed indicated no relevant financial relationships. Fabrizio Michelassi indicated no relevant financial relationships. Ole Vielemeyer indicated no relevant financial relationships. Rhonday Yantiss indicated no relevant financial relationships. Carlos Retally indicated no relevant financial relationships. Dana Lukin: Abbvie – Consultant, Grant/Research Support. Janssen – Grant/Research Support. Takeda – Grant/Research Support.
Aiya Aboubakr, MD1, Waseem Ahmed, MD2, Fabrizio Michelassi, MD1, Ole Vielemeyer, MD3, Rhonday Yantiss, MD3, Carlos Retally, MD4, Dana J. Lukin, MD, PhD2. P1672 - An Unexpected Companion: A Case of Stricturing Crohn’s Disease Ileitis With Severe Histoplasmosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.