Life-Threatening Venous Thromboses in Two Pediatric Patients Receiving Infliximab for Treatement of Inflammatory Bowel Disease

Abstract

Infliximab therapy is an effective treatment in many patients with IBD. A variety of thrombotic complications have been reported in patients receiving this therapy including pulmonary embolism, deep venous thrombosis of both the upper and lower extremities, Budd-Chiari Syndrome (BCS), and retinal vein thrombosis. We report two cases of thrombotic complications in pediatric patients with inflammatory bowel disease receiving infliximab therapy. The first patient, a 15 year old Caucasian female, was hospitalized with an exacerbation of her ulcerative colitis. Medical therapy included solumedrol and a 5-ASA product. She did not tolerate therapy with azathioprine and it was decided to administer infliximab prior to consideration for colectomy. Within less than 1 week of the initial dose, the patient developed significant diffuse abdominal pain. CT of the abdomen showed the heterogeneous enhancement of the liver with no opacification of the hepatic veins consistent with BCS. Doppler studies and transjugular venogram confirmed the diagnosis. Needle biopsy of the liver showed centrilobular sinusoidal dilation and hemorrhage with hepatocyte injury, consistent with BCS; no fibrosis was present supporting the acute presentation. The second patient was an 11 year old Caucasian female with longstanding Crohn's disease, also admitted to the hospital for an exacerbation of her disease. She also was on IV solumedrol and antibiotic therapy, but demonstrated no clinical improvement. Infliximab was administered and her diarrhea improved. Eleven days following initial infusion, however, the patient developed a severe headache, disorientation, slurred speech and twitching of the right eye. Head CT showed thrombosis of the left transverse and sigmoid dural venous sinuses with resultant venous infarction and parenchymal hemorrhage.Both patients had extensive hematologic evaluation and no underlying thrombophilia was diagnosed. The precise etiologies of venous thrombosis in these patients remains uncertain. The temporal relation of the occurrence of cerebral vascular thrombosis as well as the case of BCS each occuring within less than 2 weeks of the initial infliximab treatment raises concern for these representing possible medication-related complications. The purpose of this abstract is to increase awareness about venous thrombosis as a potential complication of infliximab therapy in patient's with IBD.