Rare cause of rectal stenosis in a patient with long-term use of Infliximab and Mercaptopurine for ulcerative colitis.
Gut. 2018 Oct 09;:
Authors: Hammoudi N, Gardair C, Tran-Minh ML, Allez M, Gornet JM
QUESTION: A 58-year-old, non-smoker male patient with no family history was followed up since 2002 for ulcerative colitis (UC) located in the rectosigmoid. He was initially treated by salicylates alone until November 2008. Mercaptopurine was started in August 2009 for steroid dependence with primary failure despite adequate 6 thioguanine nucleotides (6 TGN) level. He was included in February 2010 in the PURSUIT trial testing Golimumab with only partial response. A combination therapy with Mercaptopurine and Infliximab was then started in December 2010 with a long-term clinical, biological and endoscopic steroid-free remission. A pan-chromoendoscopy performed in June 2016 showed a complete mucosal healing with no histological activity or dysplasia on multiple random biopsies. Regular monitoring of Infliximab trough levels and 6-TGN were appropriate. A rectosigmoidoscopy was carried in September 2017 for a relapse (figure 1A), scored UCEIS 3. Rectal biopsies showed a polymorphic inflammatory infiltrate with no dysplasia. Bacterial cultures were negative. A new Infliximab infusion was administered without clinical improvement. He was hospitalised in October 2017 for poor general state, fever and persistent bloody diarrhoea. A CT scan of the chest, abdomen and pelvis found multiple mesenteric and peri-aortic lymphadenopathies, peritoneal infiltration with bilateral pyelocaliceal dilatation and major rectal thickening (figure 1B). The rectosigmoidoscopy revealed a stenosis from 5 to 20 cm from the anal verge passable by the fiberscope only (figure 1C). Biopsies were performed (figure 1D).gutjnl;gutjnl-2018-317069v1/F1F1F1Figure 1(A) Endoscopic view of the rectosigmoid (27 September 2017). (B) Abdominopelvic tomodensitometry: sagittal plane (17 October 2017). (C) Endoscopic view of the rectosigmoid (17 October 2017). (D) Anatomopathological examination of the biopsies performed.
QUESTION: What is the diagnosis?
PMID: 30301770 [PubMed – as supplied by publisher]