Improvement of Cardiomyopathy after Infliximab Treatment for Crohnʼs Disease (CD)

Abstract

Rare instantes for cardiovascular complications of Inflammatory Bowel Disease have been reported, including valvular insufficiency, conduction disorders, pericarditis, myocarditis, pericardial tamponade, dilated cardiomyopathies (DCM) and endomyocardial fibrosis. Caution has been advised when using infliximab (INF) in patients with heart disease, especially DCM, because of an increased risk of sudden death. We report a 17 y/o male with CD diagnosed at 9 yrs age, when he presented bloody diarrhea, weight loss and abdominal pain. He had many hospitalizations for exacerbations and perianal fistulizing disease treated with courses of steroids and 5-ASA. In 2004, progressive shortness of breath leading to mechanical ventilation prompted a diagnosis of DCM, with ejection fraction (EF) of 22%. Treatment with carvelidol and ACE inhibitors stabilized his heart disease. In 2005, he developed a retroperitoneal abscess requiring drainage and antibiotics. An colocutaneous fistula required a segmental colectomy with end colostomy and mucous fistula. In early 2006, he presented with an acute abdomen. Exploratory revealed a jejunal volvulus with necrosis and severe colonic disease, requiring segmental small bowel resection, subtotal colectomy and end ileostomy. Because of the aggressive disease, infliximab therapy was considered. EF was 36%. With close cardiac monitoring, IFX at 5 mg/Kg for a dose of 170 mg/infusion was started. Induction therapy was completed uneventfully, and 2 months later he had gained 10 lbs, steroids were discontinued, perianal fistula had closed, and EF 46%. IFX dose was adjusted by weight. By 6 months, he had 25 lbs and EF was 56%. He has continued doing well on maintenance IFX and azathioprine. Complications of the cardiovascular system by Crohn's disease are uncommon. Most of the reported complications related to CD are myocarditis and pericarditis but dilated cardiomyopathy has been described. Vasculitis is part of the pathological spectrum of inflammatory bowel disease and the most probable mechanism for cardiovascular injury. We successfully treated a patient with CD and DCM with improvement of systolic function and clinical status. We wonder whether his DCM is an undiagnosed manifestation of CD or an unrelated complicating illness.