PULMONARY HISTOPLASMOSIS IN A PATIENT WITH CROHN’S DISEASE ON ANTI-TNF INHIBITOR THERAPY
Authors: Chokshi Aastha , Fine Sean 
Published: January 2024

Abstract

INTRODUCTION
Infliximab, an anti-tumor necrosis factor (TNF) alpha inhibitor, is a commonly used biologic therapy for patients with inflammatory bowel disease (IBD). However, the increased risk of serious infections, including both new and re-activated infections, is a major concern while patients are on this therapy. Often the presence or development of such serious infections necessitates stopping treatment with anti-TNF inhibitors. We describe a case of a patient who developed Histoplasmosis while on infliximab but was later restarted on the same therapy due to risk of severe Crohn’s disease while maintaining him on ongoing Histoplasmosis treatment.

CASE DESCRIPTION
We describe the case of a 34-year-old male with a past medical history of Crohn’s disease on infliximab, hypertension, depression, and nephrolithiasis who presented to the hospital with dyspnea on exertion, cough, malaise, and night sweats, and was found to have multifocal pulmonary infiltrates on imaging, concerning for atypical pneumonia. He underwent a bronchoscopy and BAL, with pathology reports showing small oval shaped yeast within necrotic granulomas suspicious for Histoplasmosis. He was taken off infliximab and started on liposomal amphotericin for Histoplasma treatment initially, subsequently transitioned to itraconazole for total of 12 months. He was discharged home but was subsequently re-admitted to the hospital with a Crohn’s flare after being taken off infliximab. He was treated with steroids and started on vedolizumab for more gut-selectivity after a multidisciplinary risk/benefit discussion. However, patient was subsequently re-admitted with diarrhea and hematochezia, due to a Crohn’s disease flare while still on steroid taper and having received 2 doses of vedolizumab. He was transitioned to IV steroids and had a colonoscopy which showed large ulcers and mucosal inflammatory changes with a Simple endoscopic score for Crohn’s disease of 18. After a multidisciplinary discussion, he was restarted on infliximab. He was slowly tapered off steroids as his symptoms improved. Repeat colonoscopy after restarting infliximab showed improved but ongoing mucosal inflammatory changes with a Simple endoscopic score for Crohn’s disease of 7.

DISCUSSION
While anti-TNF inhibitor biologics are commonly used for patients with IBD, opportunistic and fungal infections remain a significant concern while on immunosuppressing biologic therapies, which necessitates stopping the anti-TNF inhibitor. Previously, a study has shown that it is safe to restart anti-TNF therapy after treatment for Histoplasmosis is completed for a 12-month duration. Our case shows that in patients such as ours with severe Crohn’s disease flares while off infliximab, treatment with anti-TNF inhibitors can be resumed after having a multidisciplinary risk/benefit discussion.
Figure 1 Colonoscopy findings showing large ulcers and significant mucosal inflammatory changes after patient started on vedolizumab and admitted for Crohn’s Disease flare.

Figure 2 Colonoscopy findings showing ongoing mucosal inflammation but improved from prior after restarting treatment with infliximab.