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Case Report
Disease remission after commencing naltrexone in an atypical case of Crohn’s disease complicated by recurrent Clostridium difficile infection
1 Department of Gastroenterology, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
Address correspondence to:
Afrasyab Khan
Department of Gastroenterology, Middlemore Hospital, 100 Hospital Road, Otahuhu,
New Zealand
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Article ID: 101014Z01AK2019
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Khan A, Perry J. Disease remission after commencing naltrexone in an atypical case of Crohn’s disease complicated by recurrent Clostridium difficile infection. Int J Case Rep Images 2019;10:101014Z01AK2019.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.
Keywords: Clostridium difficile, Crohn’s Disease, Faecal microbial transplant, Naltrexone, Necrotizing granulomas
SUPPORTING INFORMATION
Author Contributions
Afrasyab Khan - Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
John Perry - Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guaranter of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this case report.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Open Access StatementAll relevant data are within the paper and its Supporting Information files.
Copyright© 2019 Afrasyab Khan et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
