Clinician-to-Clinician Update Clinician-to-Clinician Update

Complication of Crohn’s Disease Treated with Microbiota Transplant

June 2017

Contributed by Boris Sudel, MD

Young patients with inflammatory bowel disease (IBD) face an increased risk of infections. As a factor promoting intestinal dysbiosis, IBD is associated with increased risk of Clostridium difficile infection (CDI).1 In this case, a young patient whose Crohn’s disease was in clinical remission finds his symptoms re-emerge and receives a diagnosis of CDI. Careful screening and a novel treatment help resolve symptoms and restore the patient to healthy growth and development.

Patient

A 12-year-old male patient with recurrent fever, aphthous ulcers, and rapid weight loss of 10 pounds was referred for further evaluation to the Pediatric Specialty Care Discovery Clinic at University of Minnesota Masonic Children’s Hospital. Screening for immune deficiency and infection was negative. Colonoscopy and upper GI endoscopy confirmed diagnosis of Crohn’s disease.

June-2017-Peds-IBD-Consult-Case-Study-Image
— Clostridium difficile on agar plate. Image ©iStock.

Management

The patient did not respond to partial enteral nutrition, and treatment with 5-aminosalicylates. His symptoms subsided with subsequent corticosteroid induction. After being weaned off steroids and on to the immunomodulator 6-mercaptopurine (6MP), the patient again experienced recurrence of fever and diarrhea. 6MP was switched to methotrexate, and it was partially successful in maintaining remission of symptoms, but only for a few months. The patient was switched to infliximab, which produced temporary relief of a similar duration. Finally, methotrexate in combination with adalimumab induced a sustained remission of symptoms in this patient. He gained weight and began actively participating in school sports.

At the age of 14, the patient again developed weight loss and diarrhea. Stool studies revealed CDI. He had multiple courses of antibiotic therapy and while he responded well, he always had recurrence of symptoms and CDI a few weeks to a month later. Due to difficulty in eradicating the recurrent CDI, we proposed treating the infection with a fecal microbiota transplant, in which fecal matter from a healthy donor is placed in the patient’s lower GI tract. The patient and family agreed, and the fecal microbiota transplant was performed. CDI resolved completely postprocedure.

The patient continues to be followed by his IBD care team, which includes a registered dietician and endocrine specialists. Along with his medications, the patient continues to take nutritional support in the form of liquid supplements and to have routine blood tests to monitor his nutrient status. He has achieved sustained clinical remission and has maintained healthy growth and activity in school sports for a year and a half.

Discussion

Children with IBD have been found to have high rates of recurrence of CDI compared to adults with IBD. For adults with IBD, CDI is associated with use of corticosteroids or immunomodulators. IBD therapies, however, have not been found to increase the risk of CDI in the pediatric population.2

Symptoms of active IBD and CDI can mimic one another, and the biomarkers associated with CDI are elevated in active IBD, making diagnosis challenging. Antibiotics remain the recommended first-line treatment for CDI, although initialtreatment failure can be as high as 57%.2, 3 In a large retrospective study, fecal microbiota resolved severe or complicated CDI in adult patients, and it has been reported to show success in treating CDI in patients with IBD.4 The approach remains under study and has not yet received FDA approval. Although the causative connections between IBD and recurrent CDI remain unclear, the American College of Gastroenterology guidelines recommend CDI screening as a part of treating re-emerging IBD symptoms.4

References

  1. Galdys A. The ongoing challenge of Clostridium difficile in healthcare settings. MetroDoctors. May/June 2017:22-23.
  2. Hourigan SK, Sears CL, Oliva-Hemker M. Clostridium difficile infection in pediatric inflammatory bowel disease. Inflamm Bowel Dis. 2016; 22(4): 1020-1025.
  3. Mezoff E, Mann EA, Hart KW, et al. Clostridium difficile infection and treatment in the pediatric inflammatory bowel disease population. J Pediatr Gastroenterol Nutr. 2011;52:437–441.
  4. Smits LP, Bouter KEC, de Vos WM, et al. Therapeutic potential of fecal microbiota transplantation. Gastroenterol. 2013; 145(5):946-953.
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