A 45-year-old male diagnosed with Crohn's disease 10 years ago, with rectosigmoid location and fistulizing pattern at the perianal and sigmovesical level (A1L2B3 Montreal classification).
As toxic habits he recognizes moderate enolic intake and has been a smoker.
She had intolerance to metronidazole due to the development of paresthesias and was diagnosed with peripheral arthritis as an extraintestinal manifestation.
The patient developed a corticosteroid dependence which required initiation of treatment.
Initially, treatment with infliximab was started (at a rate of 5 mg/kg), and the second dose should be suspended when an infusion reaction with skin rash and glotis edema occurred.
Subsequently, she presents a severe sprout of colonic disease and reactivation of the fistulas. Azathioprine (AZA) was introduced along with full-dose corticosteroids remission.
During this bud he presents a urinary origin and a severe hemorrhagic shock that causes an obstructive uropathy with post-renal renal failure secondary to it.
The patient required surgical cleaning after failure of the endoscopic treatment with methotrexate. A bladder dilation secondary to the presence of multiple clots was decided. Consequently, an evacuating cystostomy and temporary placement of the catheter were performed.
At 12 months, she was suspended due to transaminase elevation.
At the end of 2006, the patient started treatment with adalimumab with good tolerance and clinical evolution.
Five months after initiating treatment with adalimumab, the patient came to the emergency department due to a constitutional syndrome of two months of evolution, accompanied by widespread arthromyalgia, dysthermic sensation without fever being objectified rhythm and tendency to physical examination.
An endoscopic and barium study was performed with the objective of presenting a colonic stenosis at the sigma level, as well as an important rectosigmoid mucosal activity and presence of perianal fistulas.
Only the presence of mild renal failure, hypoproteinemia and hypoalbuminemia (urea of 78 mg/dl, creatinine of 1.9 mg/dl, total protein of 5.3 g/dl and proteinuria of 24 g/dl, albumin of 2.8 g) is highlighted in the analytical.
During hospitalization, the patient presents repeated episodes of orthostatic hypotension without other accompanying symptoms, so, together with the renal alterations described above, the presence of secondary amyloidosis is suspected.
The diagnosis is confirmed by rectal biopsy, which shows by Congo red staining the presence of an amorphous eosinophilic material around the submucosal vessels, with birefringmanence in the technique performed.
The patient was assessed by the Nephrology Department and furosemide 40 mg daily was started and adalimumab was continued as maintenance treatment.
The patient then presented with an intestinal obstruction requiring a left hemicolectomy with resection of the superior rectus sheath.
In the following months, the patient presented a paulatin worsening of her renal function, with repeated hypotensive episodes, with death 5 months after the diagnosis of amyloidosis.
The main characteristics of both patients are summarized in Table I.
