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Case prepared by: Jason Daniels
GI Pathology Fellow
Attending: Elizabeth Montgomery, M.D.
  Case 38
Clinical History: This specimen was from a 51 year old man with a history of Crohn’s disease diagnosed in 1991. The patient lived in Richmond, Virginia. He had had erythema nodosum in 1997 and a history of ileal strictures (1997). The patient developed steroid-induced diabetes when treatment with steroids was used. He subsequently failed therapy with Cipro, Flagyl, Imuran, and 6-Mercapto Purine. In 12/01, he began methotrexate 25 mg IM qwk and Remicade (infliximab, anti-tumor necrosis factor-α) 5mg/kg (12/01). Remicade was increased to 10mg/kg q16 wks (6/02), to 10mg/kg q8 wks (8/04), and to 10mg/kg q6 wks (2/05). The patient developed progressive low-grade fevers, chills, anorexia, and dry cough (5/05) and was admitted to The Johns Hopkins Hospital (JHH) Gastroenterology service with jejunoileitis. An abdominal abdominal CT showed marked bowel thickening and focal narrowing consistent with Crohn's disease with a possible fistula (5/05). The patient was discharged to home (06/05). Remicade was effective for symptomatic control for 4 wks when the patient developed abdominal pain and cramps. Despite increasing Remicade, the patient was readmitted to the JHH for continued fevers and chills. Despite aggressive treatment and bowel rest with total parenteral nutrition, he underwent an emergency resection of a segment of jejunum containing a fistula. What further studies might you do?
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Choose the correct diagnosis:
  a. Studies to confirm the impression of lymphoma complicating Crohn’s disease.
  b. Serum studies to exclude common variable immunodeficiency syndrome.
  c. Special stains for organisms.
  d. Obtain drug levels of infliximab.

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