Nasal Crohn's disease /apheresis.

Extraintestinal manifestations of inflammatory bowel disease (IBD) are very common and are estimated to occur in 20–36% of patients with Crohn's disease or ulcerative colitis.1–5 The most common sites for extraintestinal manifestations include the joints, skin, mouth, and eyes. As illustrated in the case study by Wiesen and colleagues, extraintestinal manifestations can affect any organ system and cause a tremendous negative impact on the life of a patient.6 Patients with colonic disease develop extraintestinal manifestations from their disease at an increased rate. In one large series, patients with colonic involvement of their IBD were almost twice as likely to have extraintestinal manifestations compared to patients with isolated small-bowel disease (42% vs 23%).1 The exact pathogenesis of extraintestinal manifestations in IBD is unknown. One theory suggests that in genetically susceptible hosts the presentation of luminal antigens from a leaky bowel causes activation of the systemic immune system, resulting in inflammation outside of the bowel. The majority of extraintestinal manifestations such as peripheral arthritis, erythema nodosum, episcleritis, and aphthous stomatitis tends to parallel activity of the luminal disease and resolves once the underlying bowel inflammation improves. However, several extraintestinal manifestations, including axial arthritis, pyoderma gangrenosum, uveitis, and primary sclerosing cholangitis (PSC), can be active even with the remission of underlying IBD. Indeed, PSC can occur even after colectomy. In the patient discussed by Wiesen and associates, the nasal involvement of Crohn's disease appears to fall into the latter category, as her luminal disease was quiescent at the time of her nasal symptoms.6 Treatment for extraintestinal manifestations that are independent of bowel activity can be difficult, as the treating gastroenterologist needs to balance the severity of the underlying IBD and the effects of the extraintestinal manifestations on the patient's quality of life with the side effects of the medications. Various agents have been utilized, including pain medication (eg, nonsteroidal anti-inflammatory drugs such as acetaminophen), mesalamine, sulfasalazine, methotrexate, cyclosporine, tacrolimus, and steroids.7 Several studies have recently presented positive results utilizing anti–tumor necrosis factor-α antibodies for the treatment of extraintestinal manifestations of IBD. Infliximab and adalimumab have shown efficacy in IBD-associated peripheral arthritis,8 ankylosing spondylitis,9,10 and pyoderma gangrenosum.11,12 In the patient discussed by Wiesen and coworkers, the authors utilized leukocytapheresis to treat the patient's nasal involvement of Crohn's disease.6 The used filtration system (Adacolumn, Otsuka) has been shown to remove approximately 50% of activated granulocytes and monocytes from blood.13 This system has been studied in small case series and prospective studies in both ulcerative colitis and Crohn's disease with some success.13–19 The largest series published to date included 100 patients with IBD (44 patients with Crohn's disease).17 The majority of patients had steroid-refractory or steroid-dependent disease. Clinical remission was achieved in 48% of patients with ulcerative colitis and 41% of patients with Crohn's disease. Apheresis offers an alternative novel treatment option for patients with both active luminal IBD and extraintestinal manifestations related to IBD. We await the results of ongoing, multicenter, double-blind, placebo-controlled trials utilizing apheresis in the treatment of IBD.