mercaptopurine and Abscess

Perianal complications of Crohn's disease are fairly common in the adult and pediatric populations. Transrectal ultrasonography is effective for the diagnosis and follow-up of patients with anorectal abscesses and fistulas in Crohn's disease. Metronidazole and 6-mercaptopurine therapy have been used effectively to treat perianal complications of Crohn's disease in the pediatric population. Asymptomatic perianal fistulas in a patient with Crohn's disease do not require treatment. If a fistula is symptomatic and involves only a small portion of the sphincter mechanism, conventional fistulotomy may be performed with good results. Complex fistulas that involve larger areas of the sphincter are best treated by optimizing medical management and seton placement. The management of rectovaginal fistulas in the presence of Crohn's disease is controversial. Conventional fistulotomy and transvaginal mucosal advancement flap with diverting ileostomy have been advocated as primary treatment modalities. Rectovaginal fistulas secondary to ulcerative colitis may be treated by ileoanal pouch anastomosis and primary repair.

Topics: Abscess; Adult; Colitis, Ulcerative; Combined Modality Therapy; Crohn Disease; Female; Humans; Male; Mercaptopurine; Metronidazole; Proctitis; Rectal Fistula; Rectovaginal Fistula

A 36-year-old woman presented to the emergency department with a 1-day history of purulent perianal and vulvar discharge. She had a 25-year history of Crohn's disease (CD), and 13 years prior had received a total colectomy with end ileostomy. She had vulvar biopsies 5 years prior to presentation, demonstrating noncaseating granulomas consistent with metastatic Crohn's disease (MCD). Throughout the course of her disease, she had a failed treatment with adalimumab, certolizumab, methotrexate, and 6-mercaptopurine. She had received a radical vulvectomy 1 year prior to presenting to control recurrent vulvar abscesses and MCD while receiving monthly subcutaneous infliximab 10 mg/kg body weight. Dermatology was consulted at presentation, and the physical examination revealed tender, linear ulcerations with a granulated appearance and depigmentation on the natal cleft and vulva (Figures 1 and 2). Computerized tomography (CT) scan of the abdomen and pelvis indicated thickening of soft tissue without evidence of abscesses, fluid collection, or fistulae. Given the distribution and morphology of lesions with a history of biopsy-proven MCD, the patient was diagnosed with a flare of MCD.

Topics: Abscess; Adult; Crohn Disease; Female; Humans; Infliximab; Mercaptopurine; Methotrexate; Neoplasms; Recurrence

Appropriate treatment of perianal fistulas in Crohn's disease (CD) involves accurate anatomic evaluation. EUS is an accepted imaging method for this purpose. The aim of the current study was to evaluate the clinical and endosonographic characteristics of perianal fistula in CD and to assess its impact on therapy.. All CD patients referred to the Sheba medical center from June 2004 to August 2008 for EUS examination of perianal fistulas were included. Perianal fistulas were diagnosed based on a clinical examination revealing at least one perianal cutaneous orifice. Demographic, clinical and therapeutic data was obtained. EUS was performed using an ultrasound scanner producing a 360° cross sectional image of the anal sphincters.. Fifty six patients were included in the study. Four patients were excluded from the final analysis: 3 because no fistula could be detected by EUS, and one due to inability to tolerate the examination. The mean CD duration was 10±9.16 years (range 1-37). Mean perianal disease duration was 5.3±6.5 (range 1-29) years. 27 patients had perianal involvement at presentation. Among the fistulas diagnosed, 13 were simple (25%) and 39 were (75%) complex. No correlation was found between CD duration or location, patients' age and gender or fistula location with fistula type or complexity. EUS results influenced patient management in 86% of the patients.. CD-associated perianal fistulas are mainly complex. EUS is a well tolerated and informative imaging modality, with significant impact on treatment.

Topics: Abscess; Adolescent; Adrenal Cortex Hormones; Adult; Aged; Anti-Infective Agents; Anti-Inflammatory Agents; Antibodies, Monoclonal; Anus Diseases; Azathioprine; Ciprofloxacin; Crohn Disease; Cutaneous Fistula; Endosonography; Female; Humans; Immunosuppressive Agents; Incidental Findings; Infliximab; Male; Mercaptopurine; Mesalamine; Metronidazole; Middle Aged; Rectal Fistula; Retrospective Studies; Tumor Necrosis Factor-alpha; Young Adult

A 23-year-old man was admitted for treatment of acute exacerbation of ileitis and perianal abscess caused by Crohn's disease. After incision and drainage of the abscess, coupled with antibiotic therapy, 6-mercaptopurine (6-MP) was commenced. His white blood cell (WBC) count on day 12 after initiation of 6-MP was not decreased. However, on day 24 he was re-admitted because of severe myelosuppression (WBC: 300/microl), which was complicated by the recurrence of the perianal abscess. Myelosuppression was prolonged and required the administration of granulocyte colony stimulating factor (G-CSF). G-CSF was continued for 17 days to achieve recovery of his WBC count to a normal level.

Topics: Abscess; Adult; Anus Diseases; Bone Marrow; Crohn Disease; Drug Therapy, Combination; Granulocyte Colony-Stimulating Factor; Humans; Ileitis; Immunosuppressive Agents; Leukocyte Count; Male; Mercaptopurine; Mesalamine; Neutropenia

We describe an unusual case of disseminated subcutaneous abscesses caused by Nocardia asteroides in a 17-year-old female with AML undergoing allogeneic BMT. She was receiving immunosuppressive therapy with CYA and a corticosteroid for acute GVHD, and maintenance therapy with ganciclovir for interstitial pneumonia (IP) caused by CMV, but was not neutropenic. The subcutaneous abscesses spread from the primary infection on her right anterior leg to both thighs, the left buttock, both upper arms, the left forearm and right shoulder, indicating hematogenous dissemination. Nocardia asteroides was identified from biopsy material in culture. The patient was successfully treated with a combination of trimethoprim/sulfamethoxazole (TMP/SMX) and minocycline, given for 3 months. The possibility of nocardiosis should be considered in the differential diagnosis of such patients.

Topics: Abscess; Adolescent; Antineoplastic Combined Chemotherapy Protocols; Bone Marrow Purging; Bone Marrow Transplantation; Combined Modality Therapy; Cytarabine; Daunorubicin; Female; Humans; Immunocompromised Host; Incidence; Leukemia, Myeloid, Acute; Mercaptopurine; Neutropenia; Nocardia asteroides; Nocardia Infections; Opportunistic Infections; Prednisolone; Remission Induction; Skin Diseases, Infectious

Although 6-mercaptopurine is often used to treat adolescents with intractable Crohn's disease, its long-term efficacy has not yet been studied in this population. This study shows data derived from 36 adolescents (mean age +/- SD, 16.5 +/- 3.3 years; 27 males, 9 females) treated at least 6 months with 6-mercaptopurine (1.5 mg.kg-1.day-1, maximum of 75 mg/day). Sites of Crohn's disease at the start of 6-mercaptopurine therapy included 17 ileocolic, 9 pancolic, 7 small bowel, and 3 partial colon. All had received corticosteroids, sulfasalazine, antibiotics, and nutritional support for 5.0 +/- 3.0 years before administering 6-mercaptopurine, but intractable symptoms persisted. Disease activity lessened during the first year of 6-mercaptopurine, reflected by a higher Lloyd-Still disease activity score (pre, 64 +/- 9 vs. 6-mercaptopurine, 72 +/- 11; P less than 0.0001). General activity, physical examination, nutrition, and laboratory subscores all improved (P less than 0.004). Lessened disease activity occurred despite concomitant decrease in duration of prednisone use (pre, 9.5 +/- 4.2 vs. 6-mercaptopurine, 6.6 +/- 4.9 months/year; P less than 0.001) and cumulative annual prednisone exposure (pre, 3672 +/- 2106 vs. 6-mercaptopurine, 1964 +/- 1460 mg; P less than 0.0007). The frequency of perianal fistulae and abscesses also decreased (P less than 0.01) during treatment. Annual rates of hospitalization decreased in 44% of subjects during 6-mercaptopurine treatment, while increasing in only 22%. Follow-up beyond 1 year of 6-mercaptopurine treatment showed continued remission in 23 of 30 subjects. No serious complications were seen. 6-mercaptopurine is an effective long-term therapy for adolescents with intractable Crohn's disease. While inducing remission, it also has a significant steroid-sparing effect which may be of particular benefit to this population.

Topics: Abscess; Adolescent; Adult; Anti-Bacterial Agents; Child; Crohn Disease; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Male; Mercaptopurine; Prednisone; Rectal Diseases; Rectal Fistula; Sulfasalazine; Time Factors

Topics: Abscess; Antineoplastic Agents; Histocytochemistry; Humans; Leukemia, Myeloid; Male; Mercaptopurine; Middle Aged; Necrosis; Prednisone; Shwartzman Phenomenon; Skin Manifestations

Topics: Abscess; Anti-Bacterial Agents; Aspergillosis; Candidiasis; Clostridium; Electrocardiography; Escherichia coli Infections; Geriatrics; Heart Diseases; Humans; Klebsiella; Mechlorethamine; Mercaptopurine; Pathology; Proteus; Staphylococcal Infections; Statistics as Topic; Steroids; Streptococcal Infections; Surgical Procedures, Operative