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Disease remission after commencing naltrexone in an atypical case of Crohn’s disease complicated by recurrent Clostridium difficile infection

Title
Disease remission after commencing naltrexone in an atypical case of Crohn’s disease complicated by recurrent Clostridium difficile infection
Publication Type
Journal Article
Research Type
Human
Reported as
Case Report/Series/Restrospective Study
Date
March 18, 2019
Authors
Afrasyab Khan, John Perry
Institution
Waitemata District Health Board North Shore Hospital, Counties Manukau Health Middlemore Hospital
Link
Abstract

INTRODUCTION: Crohn’s disease (CD) is typically a chronic relapsing condition of the gastrointestinal tract. Granulomas can be present which are typically non-necrotizing. CD can be triggered as well as complicated by gastrointestinal infections. We present an atypical case of Crohn’s disease with necrotizing granulomas that was triggered by Clostridium difficile infection (CDI).

CASE REPORT: A 40 years woman presented with chronic diarrhoea and investigations showed CDI. With no sustained response to metronidazole and vancomycin she came forward for a colonoscopy which showed features of Crohn’s disease. This was confirmed on histology. After a period of remission on adalimumab she required a right hemicolectomy for a severe flare. The resection specimens showed necrotizing granulomas. No alternative cause for necrotizing granulomas was found. The patient had recurrent CDI during follow-up requiring faecal microbial transplant resulting in symptom resolution. Since the patient declined the traditional immunosuppressive medications used in CD due to recurrent upper respiratory tract infections, we commenced her on oral naltrexone. She has currently been in complete remission for 30 months with low dose naltrexone. Initial diagnosis was made difficult and then revisited due to infectious gastroenteritis, recurrent diclofenac use and extra-intestinal manifestations.

CONCLUSION: CD triggered by infectious gastroenteritis and other confounders can make the diagnosis challenging. Necrotizing granulomas - though uncommon - can be present in CD. Recurrent CDI is known to be more common in CD and could act a trigger of CD flares. Low dose naltrexone may be used as a potential treatment for CD in selected cases.