- Email: [email protected]
Treatment of Aseptic Liver Abscess Due to Crohn's Disease Using Infliximab
Accepted Manuscript Aseptic Liver abscess-Induced by Crohn’s Disease Successfully Treated by Infliximab Yang Yang, Dongfeng Chen
PII: DOI: Reference:
S1542-3565(17)30740-1 10.1016/j.cgh.2017.06.033 YJCGH 55315
To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 15 June 2017 Please cite this article as: Yang Y, Chen D, Aseptic Liver abscess-Induced by Crohn’s Disease Successfully Treated by Infliximab, Clinical Gastroenterology and Hepatology (2017), doi: 10.1016/ j.cgh.2017.06.033. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Aseptic Liver abscess-Induced by Crohn’s Disease Successfully Treated by Infliximab
1
RI PT
Yang Yang1, Dongfeng Chen1
Department of Gastroenterology, Institute of Surgery Research, Daping Hospital,
SC
Third Military Medical University, Chongqing, China
First Author: Yang Yang, M.D.
M AN U
E-mail: [email protected]
Correspondence author: Dongfeng Chen, M.D.,Ph.D.
TE D
E-mail: [email protected]
AC C
EP
Conflict-of-interest statement: The authors declare no conflict of interest.
ACCEPTED MANUSCRIPT
Aseptic Liver abscess-Induced by Crohn’s Disease Successfully Treated by Infliximab
RI PT
Yang Yang , Dongfeng Chen
Department of Gastroenterology, Institute of Surgery Research, Daping Hospital,
SC
Third Military Medical University, Chongqing, China
A 24-year-old girl with Crohn’s Disease was admitted to our department for
M AN U
abdominal pain, weakness, poor appetite and intermittent fever for two weeks. There were no other complaints. The patient was diagnosed with Crohn’s Disease one year earlier, manifested by abdominal pain and intermittent bloody diarrhea and demonstrated by colonoscopy with multiple biopsies. Her past medical history was significant only for Crohn’s disease. There was no history of extraintestinal manifestations. Her Crohn’s disease had been poorly
TE D
controlled more than six months with only medications included Mesalazin for treatment, disease flares were infrequent and mild, characterized by episodes of abdominal pain, bloody diarrhea with no fever. The initial evaluation revealed anemia (HGB 72 g/L) , tachycardia (heart rate, 115 beats per minute) and
EP
tenderness in the right upper quadrant. Computed tomographic imaging showed no hepatic lesions when she was hospitalized with a first-time
AC C
diagnosis of Crohn’s Disease (Fig A, arrowheads). Due to lack of improvement, an abdominal CT scan was performed again, revealing several liver masses (Fig B, arrowheads). A ultrasound-guided biopsy was performed from the largest lesion, with drainage of 2 mL of purulent material. The cultures of the purulent material were negative. Histological examination revealed an extensive neutrophilic exudate, a number of neutrophils within bile ducts. Blood cultures ultimately revealed negative results. Liver biopsy didn’t show infiltration of atypical lymphocytes. These findings weren’t consistent with a diagnosis of Hepatosplenic T-cell lymphoma. An aseptic pyogenic liver abscess induced by Crohn’s Disease was suspected.
ACCEPTED MANUSCRIPT Because her symptoms remained unchanged after the continuation of Mesalazin and Antibiotics, we treated the patient by intravenous administration of infliximab (5mg/kg), which resulted in prompt resolution of her symptoms. Follow-up administration of infliximab (5mg/kg) after the initial infusion of infliximab showed progressive improvement of liver abscess and intestinal
RI PT
inflammation (Fig C, arrowheads) and the patient is currently under maintenance therapy with infliximab every eight weeks after completing the induction with good response.
It is well known that a liver abscess can be an extraintestinal manifestation
SC
of those diagnosed with inflammatory bowel disease. The reported incidence of this disease entity in patients with CD is 114 to 297 per 100,000, a rate that is
M AN U
about 10 to 15 times higher than that found in the general population[1]. Liver abscess is a severe condition that can be life-threatening. Diagnosis relies mainly on abdominal CT scan. Liver abscess with IBD has been considered to be mainly of microbial origin. However, not all liver abscesses have identifiable pathogens, that is, aseptic liver abscess. Unitl now, the exact etiology of liver abscess in IBD is unclear, but it is speculated that increased
TE D
intestinal mucosal permeability because of the ulceration and loss of integrity of the normal mucosal barrier seems to play an significant role[2]. Clinical manifestations of liver abscess may include fever, weight loss, right upper quadrant tenderness, and elevated neutrophil count. Since most of the
EP
symptoms are nonspecific, they can be mistaken as a disease exacerbation of underlying IBD. IBD Patients with a long-term use of IBD-related medications
AC C
may also be prone to developing liver abscess. Liver abscess formed in a patient with CD who was on infliximab was reported[3]. The long-term use of corticosteroids, immune-suppressive agent and anti-TNF-α agent may predispose patients to abscess formation by their immunosuppressive effect[4], giving rise to the risk of opportunistic infection and altering gut microbiota. Based on the previously report, aseptic liver abscess may not respond to antibiotics but improve dramatically with corticosteroids[5]. In our present case, infliximab was effective for aseptic liver abscess-induced by Crohn’s Disease, and this is the first case with treatment and resolution of liver abscess-induced
ACCEPTED MANUSCRIPT by Crohn’s Disease with infliximab that in the published literature.
1.
RI PT
References
Mir-Madjlessi, S.H., M.C. McHenry, and R.G. Farmer, Liver abscess in
Crohn's disease. Report of four cases and review of the literature. Gastroenterology, 1986. 91(4): p. 987-93. 91
Bernabeu, J.L., et al., Crohn's disease and liver abscess due to
SC
2.
Pediococcus sp. Inflamm Bowel Dis, 2011. 17(10): p. 2207-8. 17 3.
Patel, T.R., K.N. Patel, and A.H. Boyarsky, Staphylococcal liver
M AN U
abscess and acute cholecystitis in a patient with Crohn's disease receiving infliximab. J Gastrointest Surg, 2006. 10(1): p. 105-10. 4.
Teague, M., L.M. Baddour, and L.D. Wruble, Liver abscess: a harbinger
of Crohn's disease. Am J Gastroenterol, 1988. 83(12): p. 1412-4. 83 Andre, M.F., et al., Aseptic abscesses: a study of 30 patients with or
TE D
without inflammatory bowel disease and review of the literature.
EP
Medicine (Baltimore), 2007. 86(3): p. 145-61. 86
AC C
5.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
PII: DOI: Reference:
S1542-3565(17)30740-1 10.1016/j.cgh.2017.06.033 YJCGH 55315
To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 15 June 2017 Please cite this article as: Yang Y, Chen D, Aseptic Liver abscess-Induced by Crohn’s Disease Successfully Treated by Infliximab, Clinical Gastroenterology and Hepatology (2017), doi: 10.1016/ j.cgh.2017.06.033. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Aseptic Liver abscess-Induced by Crohn’s Disease Successfully Treated by Infliximab
1
RI PT
Yang Yang1, Dongfeng Chen1
Department of Gastroenterology, Institute of Surgery Research, Daping Hospital,
SC
Third Military Medical University, Chongqing, China
First Author: Yang Yang, M.D.
M AN U
E-mail: [email protected]
Correspondence author: Dongfeng Chen, M.D.,Ph.D.
TE D
E-mail: [email protected]
AC C
EP
Conflict-of-interest statement: The authors declare no conflict of interest.
ACCEPTED MANUSCRIPT
Aseptic Liver abscess-Induced by Crohn’s Disease Successfully Treated by Infliximab
RI PT
Yang Yang , Dongfeng Chen
Department of Gastroenterology, Institute of Surgery Research, Daping Hospital,
SC
Third Military Medical University, Chongqing, China
A 24-year-old girl with Crohn’s Disease was admitted to our department for
M AN U
abdominal pain, weakness, poor appetite and intermittent fever for two weeks. There were no other complaints. The patient was diagnosed with Crohn’s Disease one year earlier, manifested by abdominal pain and intermittent bloody diarrhea and demonstrated by colonoscopy with multiple biopsies. Her past medical history was significant only for Crohn’s disease. There was no history of extraintestinal manifestations. Her Crohn’s disease had been poorly
TE D
controlled more than six months with only medications included Mesalazin for treatment, disease flares were infrequent and mild, characterized by episodes of abdominal pain, bloody diarrhea with no fever. The initial evaluation revealed anemia (HGB 72 g/L) , tachycardia (heart rate, 115 beats per minute) and
EP
tenderness in the right upper quadrant. Computed tomographic imaging showed no hepatic lesions when she was hospitalized with a first-time
AC C
diagnosis of Crohn’s Disease (Fig A, arrowheads). Due to lack of improvement, an abdominal CT scan was performed again, revealing several liver masses (Fig B, arrowheads). A ultrasound-guided biopsy was performed from the largest lesion, with drainage of 2 mL of purulent material. The cultures of the purulent material were negative. Histological examination revealed an extensive neutrophilic exudate, a number of neutrophils within bile ducts. Blood cultures ultimately revealed negative results. Liver biopsy didn’t show infiltration of atypical lymphocytes. These findings weren’t consistent with a diagnosis of Hepatosplenic T-cell lymphoma. An aseptic pyogenic liver abscess induced by Crohn’s Disease was suspected.
ACCEPTED MANUSCRIPT Because her symptoms remained unchanged after the continuation of Mesalazin and Antibiotics, we treated the patient by intravenous administration of infliximab (5mg/kg), which resulted in prompt resolution of her symptoms. Follow-up administration of infliximab (5mg/kg) after the initial infusion of infliximab showed progressive improvement of liver abscess and intestinal
RI PT
inflammation (Fig C, arrowheads) and the patient is currently under maintenance therapy with infliximab every eight weeks after completing the induction with good response.
It is well known that a liver abscess can be an extraintestinal manifestation
SC
of those diagnosed with inflammatory bowel disease. The reported incidence of this disease entity in patients with CD is 114 to 297 per 100,000, a rate that is
M AN U
about 10 to 15 times higher than that found in the general population[1]. Liver abscess is a severe condition that can be life-threatening. Diagnosis relies mainly on abdominal CT scan. Liver abscess with IBD has been considered to be mainly of microbial origin. However, not all liver abscesses have identifiable pathogens, that is, aseptic liver abscess. Unitl now, the exact etiology of liver abscess in IBD is unclear, but it is speculated that increased
TE D
intestinal mucosal permeability because of the ulceration and loss of integrity of the normal mucosal barrier seems to play an significant role[2]. Clinical manifestations of liver abscess may include fever, weight loss, right upper quadrant tenderness, and elevated neutrophil count. Since most of the
EP
symptoms are nonspecific, they can be mistaken as a disease exacerbation of underlying IBD. IBD Patients with a long-term use of IBD-related medications
AC C
may also be prone to developing liver abscess. Liver abscess formed in a patient with CD who was on infliximab was reported[3]. The long-term use of corticosteroids, immune-suppressive agent and anti-TNF-α agent may predispose patients to abscess formation by their immunosuppressive effect[4], giving rise to the risk of opportunistic infection and altering gut microbiota. Based on the previously report, aseptic liver abscess may not respond to antibiotics but improve dramatically with corticosteroids[5]. In our present case, infliximab was effective for aseptic liver abscess-induced by Crohn’s Disease, and this is the first case with treatment and resolution of liver abscess-induced
ACCEPTED MANUSCRIPT by Crohn’s Disease with infliximab that in the published literature.
1.
RI PT
References
Mir-Madjlessi, S.H., M.C. McHenry, and R.G. Farmer, Liver abscess in
Crohn's disease. Report of four cases and review of the literature. Gastroenterology, 1986. 91(4): p. 987-93. 91
Bernabeu, J.L., et al., Crohn's disease and liver abscess due to
SC
2.
Pediococcus sp. Inflamm Bowel Dis, 2011. 17(10): p. 2207-8. 17 3.
Patel, T.R., K.N. Patel, and A.H. Boyarsky, Staphylococcal liver
M AN U
abscess and acute cholecystitis in a patient with Crohn's disease receiving infliximab. J Gastrointest Surg, 2006. 10(1): p. 105-10. 4.
Teague, M., L.M. Baddour, and L.D. Wruble, Liver abscess: a harbinger
of Crohn's disease. Am J Gastroenterol, 1988. 83(12): p. 1412-4. 83 Andre, M.F., et al., Aseptic abscesses: a study of 30 patients with or
TE D
without inflammatory bowel disease and review of the literature.
EP
Medicine (Baltimore), 2007. 86(3): p. 145-61. 86
AC C
5.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT