S2245 A Whipping Case of Crohn's Disease

Abstract

INTRODUCTION: Crohn’s disease (CD) is a chronic inflammatory disorder (CID) of the gastrointestinal (GI) tract characterized by an impaired gut immune response with an altered microbiome. Prevalence is higher in developed countries where immune system exposures may be limited by more sanitary environments. In developed countries, improved hygiene, the rarity of parasitic infections and the occasional clearing of beneficial bacteria from the intestinal tract are thought to possibly predispose individuals to develop immunologic diseases. Despite an expanding therapeutic armamentarium, CD can be difficult to treat, driving some patients to seek alternative therapies. Here we present a case describing the controversial use of helminthic therapy (HT) for self-treatment of CD. CASE DESCRIPTION/METHODS: A 50-year-old male with a history of iron deficiency anemia (IDA) and Crohn’s colitis maintained on infliximab and 6-mercaptopurine combination therapy, presented for a surveillance colonoscopy. In the distal sigmoid colon, there were scattered erosions and a few clean-based ulcerations with associated mucosal erythema and friability. Numerous, 3-5 mm, white, linear worms were also noted throughout the colon. Infliximab levels and thiopurine metabolites were sub-therapeutic, concerning for poor compliance. The patient later admitted to surreptitiously consuming whipworm eggs for CD self-treatment which he obtained online. Despite worsening IDA, weight loss and lack of improvement of symptoms related to CD, the patient declined treatment for whipworm. DISCUSSION: Helminths have been shown to reduce immune responsiveness in naturally colonized individuals and to diminish inflammation in experimental colitis. Helminths are thought to induce a strong Th2 response that counterbalances an overactive Th1/Th17 response seen in CIDs. The majority of studies with HT in this setting; however, have failed to demonstrate clinical efficacy; although, some report improvements in CD-related symptoms. Common complications related to HT include IDA, diarrhea, anorexia, dehydration and dysentery. Overall, HT for CD is not advised as it is controversial, of limited therapeutic efficacy, not FDA approved and can lead to more complications than therapeutic benefits.Figure 1.: Endoscopic image showing multiple white whipworms within the colon.Figure 2.: Endoscopic image of 5 mm, white, linear whipworm. Pseudopolyposis also seen in this image.