Dados do Trabalho

Title

ENTEROPATHIC SPONDYLITIS: TREATMENT, PANCYTOPENIA AND PORTAL HYPERTENSION IDIOPATHIC

Background

Inflammatory bowel disease (IBD) is the term currently used to denote Crohn's disease and ulcerative colitis. They can affect 2 to 20 individuals per 200,000 people and joint involvement can affect 2% to 26% of patients with IBD. These conditions may be subdivided into peripheral oligoarthritis, peripheral polyarthritis, and enteropathic spondylitis. Enteropathic spondylitis can affect 2% to 12% of patients; predominates in men and 50% to 75% of these patients present HLA-B27; the clinical condition is similar to that observed in ankylosing spondylitis and the evolution is usually independent of the intestinal conditions. Treatment is based on corticosteroids at low or high doses in cases of major intestinal inflammation. In severe cases of recurrence, the use of methotrexate, azathioprine, infliximab and adalimumab may be indicated.

Case report

O.S.C, 25, admitted to emergency room (2013) with a previous diagnosis of Chron's disease. He presented complications during the treatment and had surgical procedures to control the disease. In addition, he used azithromycin 150mg/day, but due to the appearance of joint and pancytopenia, an reumatology's evaluation was requested. He was diagnosed with enteropathic spondylitis and optimized the treatment for infliximab 100mg/month. He maintained with moderate control of IBD and improvement of the joint symptoms, but due to the persistence of pancytopenia and the appearance of hepatosplenomegaly, he was referred to hematology and gastroenterology services. After extensive investigation and ruled out causes of malignancy; portal hypertension (21mm caliber portal vein) and homogeneous splenomegaly (24cm) were found. The medical team concludes that clinical condition occurred due to the use of immunosuppressants (exclusion diagnosis). Currently, the patient has good control of the comorbidities.

Conclusion

The case is important due to relationship of the treatment of enteropathic spondylitis with pancytopenia and hypersplenism. The objective is to highlight aspects of the potentially serious side effects of these medications: myelotoxicity and idiopathic portal hypertension (HPI). Despite the improvement in the joint and bowel, the side effects became relevant. The synthetic analog of purine is described as causing myelotoxicity. Pancytopenia is also associated with the use of anti-TNF. In addition, observed HPI had like only objective causal factor the prolonged use of azathioprine. That is a rare occurrence, but should be considered as differential diagnosis, particularly in patients undergoing thiopurine treatment for long periods. As it was not clear which drug or combination was responsible for the adverse effects, we emphasize the importance of patient care and monitoring when using powerful immunosuppressive agents.