De novo Crohnʼs Disease After Stem Cell Transplantation

Abstract

A 49 year-old woman with history of acute lymphocytic leukemia (ALL) underwent chemotherapy and subsequently achieved complete remission of disease. She was high-risk for relapse and subsequently received allogeneic stem cell transplant (SCT). After SCT, she developed refractory diarrhea, and was referred to our clinic. The patient had two prior episodes of Clostridium difficile infections prior to her SCT, which were treated. Despite elimination of toxin, the diarrhea continued. Routine stool studies were negative. The patient subsequently underwent endoscopic evaluation with biopsies. During her fourth colonoscopic evaluation, biopsies demonstrated a variable chronic active colitis with epithelioid cell granulomas. Acid-fast bacilli and Gomori methenamine silver (GMS) stains were negative for microorganisms. Cytomegalovirus, Epstein-Barr virus, and Adenovirus were negative on viral cultures. While the histological features could arise in the setting of graft-versus-host disease, the nature and pattern of inflammation were more characteristic of Crohn's disease. The patient was subsequently initiated on corticosteroids and mesalamine, with improvement in her symptoms of diarrhea to her baseline. Despite reported cases of potential treatment of Crohn's disease with SCT, here we report a case of de novo Crohn's disease with onset that may have been influenced by SCT. Multiple factors are implicated in the pathogenesis of Crohn's disease, including genetics, environment, infection, and immunologic factors. This case suggests that susceptibility to Crohn's disease may be transferred during SCT. Further studies are warranted to elucidate understanding of this relationship, so that we may identify appropriate recipients and donors for SCT, given our knowledge that inflammatory bowel disease may have a multifactorial genesis.