A 35-year-old woman with a family history of Crohn's disease and no relevant pathological history or toxic habits presented with abdominal pain in the RIF plus weight loss.
It was studied on an outpatient basis arriving to the diagnosis of Crohn's disease with ileal and ileocecal valve involvement (A1L1B2, Vienna 1998), according to clinical, endoscopic and histological criteria.
Treatment was initiated with corticosteroids and steroids.
Due to corticoid dependence, treatment with azathioprine was started, remaining steroid-free and in complete clinical remission, with symptoms returning two years later.
The administration of infliximab was indicated, and 2 doses were administered.
Antinuclear antibodies, chest X-ray and viral serology were negative.
Two weeks later, he was admitted with fever of 39 oC, pain and difficulty to move his neck.
The previous week, the patient had presented with fever and general condition. During three days, outpatient treatment with radiation was performed.
Physical examination revealed thinness (BMI 17), temperature 37 oC, blood pressure 105/60, conscious and oriented, with normal neurological examination, normal oral muguet and cardiorespiratory and abdominal examination.
The tests showed normocytic anemia (9.9 g/dl Hb), leukocytes 6,700 with 84% segmented platelets 363,000.
The sedimentation rate was 68.
Blood biochemical parameters were normal except for GOT 87, GPT 51, gamma-GT 67 and total proteins that were 5.8 g/dl with albumin of 1,400 mg/dl. The basic abdomen of urine and sediment were normal.
Lumbar puncture was performed, detecting in the liquid exam a normal glycorrhachia, proteinorrhachia of 102 mg/dl, 960 gram cells/mm3 a 90% of them were infected by Gram-positive meningitis.
Five days after admission, the patient presented acute abdomen with intestinal peritonitis secondary to perforation of the preterminal ileum and ileum stenosis, rest of the small intestine and normal colon.
Ileo-cecal resection and terminal ileostomy with ascending colon mucosal fistula were performed.
Pathological examination confirmed granulomatous inflammation compatible with Crohn's disease.
The evolution was favorable, completing antibiotic therapy with ampicillin and gentamicin for three weeks, with negative CSF at discharge.
Azathioprine was restored once the infection was stable and overcome, being discharged 21 days after admission.
