Letters to the Editor
7. Ginsburg PM, Hanan I, Ehrenpreis ED. Treatment of severe esophageal Crohn’s Disease with thalidomide. Am J Gastroenterol. 2001;96 (4): 1305–6. 1
Department of Medicine, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA; 2Gastroenterology Consultants, Hollywood, Florida, USA; 3Division of Gastroenterology, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA. Correspondence: Jodie A. Barkin, MD, Department of Medicine, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida 33101-9132, USA. E-mail:
[email protected]
Successful Use of Infliximab in the Treatment of Corticosteroid Dependent Collagenous Colitis
then hospitalized for dehydration and given intravenous steroids. Stool culture grew aeromonas hydrophilia caviae and this was treated to eradication with trimethoprim-sulfamethoxazole. The patient had persistent symptoms and was discharged on 6-mercaptopurine 50 mg daily, octreotide 50 mcg subcutaneous injection twice daily, and prednisone. Four weeks later, the patient was hospitalized for acute pancreatitis due to the 6-mercaptopurine; this was discontinued. Other unsuccessful treatment attempts included alosetron 1 mg twice daily, tincture of opium, and Boswellia serrata extract. She then came to our medical center where she underwent
esophagogastrojejunoscopy with jejunal biopsies, which were negative for celiac disease. A neuroendocrine tumor work-up was negative including calcitonin, vasoactive intestinal peptide, and 24 h 5-hydroxyindoleacetic acid. Magnetic resonance enterography was normal. Colonoscopy was repeated, again confirming the diagnosis of collagenous colitis (Figure 1a). After 18 months of symptoms the patient was considered for colectomy with reversal of her roux-eny gastric bypass, but salvage therapy was attempted with infliximab with induction dosing (5 mg/kg intravenously at weeks 0, 2, and 6) with oral methotrexate 12.5 mg/week. A mild transaminase
Suresh Pola, MD1, Marianne Fahmy, MD1, Elisabeth Evans, NP1, Ann Tipps, MD2 and William J. Sandborn, MD1 doi:10.1038/ajg.2013.43
To the Editor: A 58-year-old woman status-post roux-en-y gastric bypass for obesity experienced 2 months of diarrhea with up to 12–15 watery bowel movements daily along with nighttime symptoms and fecal incontinence. After stool cultures, ova and parasite examination, and C. difficile toxin PCR were unrevealing for infection, the patient underwent colonoscopy and was diagnosed with collagenous colitis based on an endoscopically normal appearing colon and classic histology on random biopsies. The patient had been taking ibuprofen and a dexlansoprazole and both were discontinued. The patient was initially treated with budesonide 9 mg daily. The patient had no response and was given adjunctive therapies including diphenoxylate/ atropine, loperamide, and bismuth with no response. She was given mesalamine but this was held due to nausea and vomiting. The patient also failed a trial of cholestyramine for 1 month. The patient had then had 6 months of diarrhea and experienced a 10-lb weight loss and was © 2013 by the American College of Gastroenterology
Figure 1. (a) Before treatment with infliximab, colon biopsies revealed collagenous colitis, due to the presence of focal thickening of the subepithelial collagen table (arrows) with irregular borders with the lamina propria and areas of superficial denudation associated with the collagenous thickening. (b) After 6 months of treatment with infliximab, patient’s colon biopsy revealed benign colonic mucosa with no significant histopathology.
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elevation was successfully managed with a dose reduction to 7.5 mg of weekly oral methotrexate. The patient began to notice some improvement in her symptoms and was able to begin tapering her prednisone at week 4 of infliximab treatment. Repeat colon biopsies at week 5 of infliximab therapy revealed persistent collagenous colitis. The patient discontinued prednisone at 8 weeks without recurrence of diarrhea, and gradually returned to her baseline weight. Following induction therapy, infliximab maintenance therapy (5 mg/kg intravenously every 8 weeks) was administered. At ~6 months following infliximab initiation, the patient remained asymptomatic and free of corticosteroids. Repeat colon biopsies revealed a normal appearing colon with no evidence of collagenous colitis (Figure 1b). Relapse and steroid dependence is not uncommon in microscopic colitis. Anti-tumor necrosis factor use has been reported as successful in 5/7 patients with refractory microscopic colitis (1,2). We demonstrate the successful use of infliximab in a patient with severe refractory collagenous colitis resulting in symptomatic and histologic remission. Anti-tumor necrosis factor therapies can be considered in patients with refractory or corticosteroid dependent collagenous colitis. CONFLICT OF INTEREST
William J. Sandborn received research support and is a consultant to Janssen, Abbvie (formerly Abbott Laboratories), and UCB Pharma. The other authors declare no conflict of interest. REFERENCES 1. Esteve M, Mahadevan U, Sainz E et al. Efficacy of anti-TNF therapies in refractory severe microscopic colitis. J Crohns Colitis 2011;5:612–8. 2. Munch A, Ignatova S, Strom M. Adalimumab in budesonide and methotrexate refractory collagenous colitis. Scand J Gastroenterol 2012;47:59–63. 1 Division of Gastroenterology, Inflammatory Bowel Disease Center, UC San Diego Health System, La Jolla, California, USA; 2Department of Pathology, UC San Diego Health System, San Diego, California, USA. Correspondence: William J. Sandborn, MD, UC San Diego Health System, 9500 Gilman Drive, La Jolla, California 92093-0956, USA. E-mail:
[email protected]
The American Journal of GASTROENTEROLOGY
Fosfomycin-Containing Second-Line Treatment For Helicobacter pylori Infection Josué Barahona-Garrido, MD1,2, Nery F. Quiñonez, MD3, Eduardo Cerda-Contreras, MD, PhD4, Helga Maria Sarti, MD5 and Félix I. Téllez-Ávila, MD, PhD6 doi:10.1038/ajg.2013.48
To the Editor: Multi-drug resistant Helicobacter pylori (H. pylori) infection is a common problem in some countries (1). In Guatemala, in vitro resistance to amoxicillin (AMO) and clarithromycin (CLA) has been reported to be of 31% and 85%, respectively, suggesting that this first-line antibiotic combination may have high rate of failure (2). A retrospective analysis of Guatemalan patients that received a proton-pump inhibitor (PPI)/AMO/CLA as first-line therapy for H. pylori infection found that effectiveness is < 50% (3). In vitro resistance rate to metronidazole (MET) was also reported to be high (100%) (2); therefore, secondline treatment that includes this antibiotic seems to be a non-feasible option. Tetracycline (TET) is also recommended as part of second-line treatment; in Guatemala, it has lower in vitro resistance rate than the above-mentioned antibiotics (12%) and is similar than observed with levofloxacin (LEV) (4%) (2). Recently, owing to the elevated rate of AMO, CLA and MET resistant H. pylori strains, eradication treatments that include LEV has been evaluated and found to be effective. Tursi et al. (4) and Chuah et al. (5) reported that the second-line treatment of LEV/TET is effective against H. pylori infection (4,5). Despite LEV effectiveness, it is known the problem of a rising rate of resistance, mainly in some countries of Latin America (Peru, 36.9%) (6), Asia (Taiwan, 32.3%) (7), and Europe (Spain, 14.5%; Western/Central and Southern Europe, > 20%) (8,9); therefore, we think that indiscriminate use of this antibiotic should be avoided. The Maastritch IV/
Florence Consensus and the World Gastroenterology Organization recommend H. pylori culture to determine the best therapeutic option after a second failure treatment (10,11). In Guatemala, culture for H. pylori is not widely available; thus, antibiotics with low rate of resistance are required to provide effective eradication as empirical rescue treatment. Fosfomycin (FOS) is a broad-spectrum antibiotic successfully used to treat urinary tract infections (12,13). Blacky et al. (14) reported that in vitro combination of FOS with AMO or CLA have partial synergistic activity and suggested that this combination may be an alternative to treat H. pylori infection The effectiveness of FOS as treatment for H. pylori infection remains unknown. We want to report that we tested the in vitro activity of FOS against 10 strains of H. pylori obtained from 10 consecutive patients who failed first-line PPI/AMO/ CLA treatment. Gastric biopsies were processed according the Bauer & Kirby and agar diffusion disk methods (2). We found that 10 strains were susceptible to FOS, 2 to AMO, 1 to CLA, 1 to MET, 9 to TET, and 9 to LEV. Our results suggest that second-line rescue treatment that include MET may not be an effective option for this patients. After these results, due to the high prevalence of resistance to MET in our population we decided to change second-line empirical treatment that includes PPI/ MET/TET/bismuth (BIS) to the combination of PPI (esomeprazole 40 mg b.i.d.)/FOS (500 mg t.i.d.)/TET (500 mg q.i.d.)/BIS (bismuth subsalicylate 262 mg q.i.d.) in a group of 20 consecutive patients who failed conventional first-line PPI/AMO/CLA therapy (from January to October 2012) confirmed with a positive result for H. pylori stool antigen 4–8 weeks after treatment completion. We found that H. pylori eradication was achieved in 19 (95%) patients, with a compliance of 100% and only mild secondary adverse effects (headache, nausea, abdominal pain, and bloating) presented in 5 (25%) patients. In conclusion, we think that FOS may be a promising treatment option as part of an empirical second-line H. pylori eradication treatment in a country with high prevalence of resistance to MET. This is the VOLUME 108 | MAY 2013 www.amjgastro.com
