Corticosteroid Tapering Research Articles

57-Year-Old Man With Hip Pain and Lytic Bone Lesions

57-year-old man presented to his primary care physician with a 2-year history of progressive right hip pain. His medical history was notable for hyperlipidemia. He was up-to-date on sex- and agespecific cancer screening. The patient had no history of chest pain, palpitations, shortness of breath, cough, or other cardiac, respiratory, neurologic, or visual symptoms. He had no recent travel history or occupational or social contact with persons who were ill. Physical examination revealed an obese man (body mass index [calculated as weight in kilograms divided by height in meters squared], 40.34 kg/m 2 ) with normal vital signs and unremarkable findings on cardiac, respiratory, abdominal, neurologic, and lymphatic examination. No pain or tenderness was elicited on examination. He was treated initially with nonopioid pain medications. Sacroiliac corticosteroid injections were minimally beneficial. Results of a complete blood cell count (CBC) and electrolyte panel were normal with the exception of an elevated serum calcium level of 11.7 mg/dL (reference range, 8.9-10.1 mg/dL). Ultimately, magnetic resonance imaging (MRI) of his lumbar spine revealed numerous punched-out lytic lesions in the lumbar vertebra and pelvis. He underwent computed tomography (CT) of his chest, abdomen, and pelvis that identified further lytic lesions as well as multiple splenic lesions concerning for metastases. Two separate CT-guided bone biopsy samples of the lytic lesions in the lumbar vertebra did not elicit an etiology of the lesions.

Benefit of adjunctive tacrolimus in connective tissue disease-interstitial lung disease

We evaluated the safety and effectiveness of adjunctive tacrolimus therapy with conventional immunosuppression in patients with severe connective tissue disease-related interstitial lung disease (CTD-ILD).We included patients from our interstitial lung disease (ILD) registry with CTD-ILD, in whom tacrolimus was added to corticosteroids and an additional immunosuppressive agent. Demographic data, clinical features, lung function, radiographic images, and pathologic findings were reviewed. Effectiveness was assessed by comparing pulmonary function tests (PFTs) closest to tacrolimus initiation to PFTs approximately 6–12 months later. Corticosteroid dose at these time points was also evaluated. We report adverse events attributed to tacrolimus.Seventeen patients with CTD-ILD were included in adverse event analysis; twelve were included in efficacy analysis. Length of tacrolimus therapy ranged from 6 to 110 months (mean 38.8 months ± 31.4). The mean improvement in percent predicted total lung capacity was 7.5% ± 11.7 (p = 0.02). Forced vital capacity mean improvement was 7.4% ± 12.5 (p = 0.06). The average decrease in corticosteroid dose at follow-up was 20.3 mg ± 25.2 (p = 0.02) with complete discontinuation in six patients. No patients experienced a life-threatening adverse event attributed to tacrolimus.Tacrolimus can be effective and is well tolerated as an adjunctive therapy and allows tapering of corticosteroids.

Intracranial Hypertension in Cystinosis Is a Challenge: Experience in a Children's Hospital.

Cystinosis is a rare systemic lysosomal disease affecting mainly the kidney and eye. Ocular involvement in cystinosis is universal being the presence of cystine crystals in the cornea a diagnostic criterion and one of the earliest manifestations of the disease. Neuro-ophthalmologic manifestations are considered a rare and late complication in these patients. The aim of this article is to report the unexpectedly high incidence of intracranial hypertension in children with cystinosis at our centre. This study included eight children (0-16years of age) with cystinosis seen at the paediatric ophthalmology department, Hospital Universitari Vall d'Hebron (Barcelona, Spain), a tertiary hospital, over the last 5 years. Three girls and five boys, mean age: 9.6years (range: 5-14years), were studied. During follow-up, 4 out of 8 developed papilledema and confirmed high cerebrospinal fluid (CSF) pressure. The only symptomatic child presented an Arnold-Chiari anomaly with enlarged ventricles, whereas the other three, all asymptomatic, were diagnosed by scheduled fundoscopy and had normal neuroimaging studies. All four patients had at least one known risk factor for developing intracranial hypertension: initiation of growth hormone therapy, tapering of corticosteroids, acute renal failure and Arnold-Chiari malformation. Two of them required a ventriculoperitoneal shunt. Our results show that intracranial hypertension can occur more frequently than expected in patients with cystinosis. Furthermore, visual prognosis depends on early diagnosis and prompt treatment. A multidisciplinary approach is necessary, and we recommend fundoscopic examinations in all paediatric patients with cystinosis whether or not they present symptoms.

Tolosa Hunt Syndrome: Increased Severity on Second Attack

Tolosa Hunt syndrome (THS) is a rare cause of painful ophthalmoplegia with an estimated annual incidence of 1 case per million per year. It is caused by a nonspecific inflammatory process, of unknown etiology, involving the cavernous sinus, the superior orbital fissure and/or the orbital apex. It is classically described as an episodic orbital pain associated with paralysis of one or more of the 3rd, 4th and 6th cranial nerves, resolving spontaneously or with the commencement of steroids. I report a female patient who had 2 attacks of THS separated by a period of 10 months. She presented with retro-orbital headache, exophthalmos, and ophthalmoplegia of left eye, on both attacks, and was treated with high dose prednisolone. On first attack she improved within 6 weeks of treatment. On second attack, the patient had a higher Erythrocyte sedimentation rate (ESR) and developed 2 relapses on corticosteroids tapering, requiring a prolonged course of treatment, for 27 weeks, which suggests that the disease activity may get more severe on further attacks of the disease.

The Clinical and Histological Spectrum of Idiopathic Inflammatory Myopathies.

Idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of myositis, characterised by chronic muscle weakness, cutaneous features, different extra-muscular manifestations and circulating autoantibodies. IIMs included classical polymyositis (PM), dermatomyositis (DM) and other different types of myositis with a wide range of muscle involvement. A complete autoantibody profile and a muscle biopsy are mandatory to correctly diagnose different clinical entities and to define their different prognosis. Bohan and Peter's criteria included five items to diagnose adult onset PM and DM. The sensitivity was 74-100%, while the specificity is low, due to a poor ability to differentiate PM from neuromuscular diseases. Other criteria included a more accurate histological definition of PM, DM or amyopathic DM, obtaining a higher specificity. Autoantibodies' association, interstitial lung disease and clinical cardiac involvement represent the main items that could define the prognosis of these patients. On the other hand, inclusion body myositis is a different myopathy characterised by a peculiar muscle mass involvement, muscle atrophy and progressive loss of function, due to complete failure to all immunosuppressive drugs used. Treatment of IIMs is based on corticosteroids (CS), which show rapid clinical response and functional improvement. Different immunosuppressant drugs are given to obtain a better control of the disease during CS tapering dose. No controlled double blind trials demonstrated the superiority of one immunesuppressant on another. The occurrence of interstitial lung involvement requires the immediate introduction of immunosuppressants in addiction to CS. Severe dysphagia seems to improve with intravenous immunoglobulins (Ig). Physical therapy could be started after the acute phase of diseases and seems to have a beneficial role in muscle strength recovery.

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See page 1206: Using multiple online databases to help identify microRNAs regulating the airway epithelial cell response to a virus‐like stimulusSee page 1241: Outcomes of rapid corticosteroid tapering in acute eosinophilic pneumonia patients with initial eosinophilia

Corticosteroid Dose Reduction With Vedolizumab Treatment of Crohnʼs Disease During the GEMINI 2 Trial

Introduction: Corticosteroids (CS) can effectively induce remission of Crohn's disease (CD), but serious side effects prohibit long-term use. Vedolizumab (VDZ) maintenance therapy resulted in a significantly higher percentage of patients with CS-free remission at week 52 versus placebo (PBO) in the GEMINI 2 study of moderately to severely active CD.1 Methods: In GEMINI 2, patients who responded to VDZ induction therapy at week 6 were re-randomized to PBO or VDZ for 46 weeks. From week 6 onward, patients with clinical response began a CS tapering regimen. With exploratory and post hoc analyses, we characterized CS dose reductions following VDZ therapy in the population of patients on stable CS doses (≤30 mg/day prednisone or equivalent) at baseline (week 0). Median CS dose over time, change from baseline CS dose, and CS-free status at week 52 were summarized overall and by tumor necrosis factor antagonist (anti-TNF) treatment (naive or failure) history. Results: At week 52, 68% of patients with baseline CS use decreased their CS dose with VDZ treatment compared with 62% with PBO (Table). The median CS dose in either treatment group (VDZ or PBO) at week 52 was 5 mg/day. Higher percentages of patients (overall and anti-TNF-naïve) had doses ≤7.5 mg/day with VDZ versus PBO (Table). In anti-TNF-naïve patients, the median CS dose at week 52 was 2.7 mg/day with VDZ and 5.0 mg/day with PBO. At week 52, higher percentages of VDZ-treated patients were CS-free for 90 or 180 consecutive days than PBO-treated patients (Table). Conclusion: VDZ maintenance therapy was associated with numerically higher percentages of CS-free patients at week 52 and patients who were CS-free for 90 or 180 days than PBO. Interpretation of these post hoc analyses, including the degree of dose reduction, is limited by differing initiation weeks for CS tapering per patient and small sample sizes.Table 1: CS Dose Reductions at Week 52

Omalizumab in patients with eosinophilic granulomatosis with polyangiitis: a 36-month follow-up study

Objective: Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis characterized by asthma and blood eosinophilia, with the lung being the organ most frequently affected. Oral glucocorticoids and/or immunosuppressive drugs are the mainstay therapy of EGPA. Occasional reports suggest that EGPA patients can be treated with omalizumab in addition to conventional therapy to achieve asthma control. To investigate the long-term effects of omalizumab in patients with EGPA and asthma (2 females, 3 males, age 41–64 years), we carried out a 36-month follow-up observational study. At the time of enrollment, the patients were on maintenance therapy and had moderate to severe allergic asthma, eosinophilia and rhinosinusitis. Mononeuropathy/polyneuropathy and/or histological evidence of tissue eosinophilic infiltration were also present. Methods: Patients were treated with omalizumab (300–600 mg s.c. every 2–4 weeks) as add-on therapy to prednisone, inhaled steroids and bronchodilators. During omalizumab treatment, spirometry, the asthma control test (ACT) score and eosinophilia were evaluated, and prednisone dosage was recorded. Results: During the 36 months of omalizumab treatment asthma progressively improved as indicated by spirometry and the ACT score. Eosinophilia progressively decreased. The oral prednisone dose was reduced or withdrawn during treatment. No adverse events were recorded. Conclusions: In patients with EGPA and moderate to severe allergic asthma, omalizumab can be beneficial and safe. It enables corticosteroid tapering while decreasing eosinophilia and improving asthma symptoms over 36 months.

Outcomes of rapid corticosteroid tapering in acute eosinophilic pneumonia patients with initial eosinophilia.

Studies have shown that patients with acute eosinophilic pneumonia (AEP) and with initial eosinophilia have a milder disease than those with an initial normal peripheral eosinophil count (PEC). We investigated the effect of a rapid corticosteroid tapering strategy in AEP patients with initial eosinophilia. We performed a prospective cohort study in patients with AEP with initial eosinophilia (n = 14) who stopped corticosteroid treatment after achieving clinical stabilization compared with AEP patients with an initial normal PEC (n = 45) who received 2-week treatment with corticosteroid. In total, 59 AEP patients were identified. The median duration of corticosteroid treatment was 4 days (interquartile ranges (IQR), 3-4) in patients with initial eosinophilia and 14 (IQR, 14-14) days in patients with initial normal PEC. No treatment failure occurred in the group with initial eosinophilia; one treatment failure case occurred in the group with an initially normal PEC. The median time to overall clinical stabilization was 3 days, and time to complete resolution of all symptoms and clinical instabilities from diagnosis was 4 days in AEP patients with initial eosinophilia. Both were significantly shorter than those) in the initially normal PEC group, which were 5 and 7 days respectively (both P < 0.001). Adverse effects were lower in AEP patients with initial eosinophilia, and additional medications to relieve adverse effects were only needed in AEP patients with initially normal PEC. Rapid corticosteroid tapering may be an acceptable treatment strategy for managing AEP patients with initial eosinophilia.

Impact of Perioperative Oral Steroid Use on Low-frequency Hearing Preservation After Cochlear Implantation.

To investigate the efficacy of a perioperative oral steroid taper on low-frequency hearing preservation after cochlear implantation. Retrospective case series. Tertiary referral center. Consecutive cochlear implant recipients between January 2012 and December 2014 who were candidates for a hearing preservation approach based on preoperative pure tone thresholds were identified. A subgroup of patients received a 2-week oral corticosteroid taper beginning 3 days before surgery. All patients were implanted using standard length electrodes. The preservation of low-frequency pure tone thresholds on the first postoperative audiogram was assessed. Secondary outcome measures included the respective impacts of age, diabetes, and electrode array type on hearing preservation, the durability of hearing preservation over time, and the development of medical complications related to steroid use. Twenty-seven ears met inclusion criterion, and the mean age at implantation was 49.8 years (median 62 yr, range 2-81 yr). Twenty patients (74.1%, mean age 48.7 yr) received an oral corticosteroid taper, whereas 7 (25.9%, mean age 53.1 yr) did not. The rate (p < 0.01) and degree (p < 0.01) of hearing preservation as measured at implant activation was greater for patients who received an oral steroid taper than those who did not. There were no medical complications related to steroid use. A 2-week oral prednisone taper beginning before surgery may positively affect the incidence and degree of low-frequency hearing preservation after cochlear implantation.

A unique case of acute transverse myelitis with Mycoplasma pneumoniae infection

Mycoplasma pneumoniae is a common cause of respiratory tract infection. Extra-pulmonary complications of M. pneumoniae infection include neurologic complications involving the central nervous system. Myelitis is one of the most severe complications of central nervous system. We report a unique case of acute transverse myelitis associated with M. pneumoniae infection in a 3-year-old boy with particular imaging and clinical course features. Intravenous corticosteroids were prescribed with an 8 wk tapering of oral corticosteroids resulting in full recovery. We postulate an immune-mediated mechanism.

Radiation-Refractory Brain Metastases in Patients with Non-Small Cell Lung Cancer.

Numerous studies have focused on the treatment of non-small cell lung cancer patients with brain metastases. However, to our knowledge, few have sought to examine outcomes in patients who required whole brain radiation and developed radiation-refractory disease. This study examined the medical records of all non-small cell lung cancer patients who developed brain metastases between 2004 and 2013, required whole brain radiation, and received their cancer treatment at the Mayo Clinic in Rochester, Minnesota. A total of 141 patients, most of whom were symptomatic, met the above criteria. Of these, 33 (23%) did not tolerate a corticosteroid taper and were therefore deemed to have radiation-refractory disease. The median survival of patients with and without radiation-refractory disease was 3.12 and 4.27 months, respectively, (hazard ratio [HR]: 0.65 [95% confidence interval (CI): 0.44-0.99]; p=0.04 by log rank test). In a subgroup analysis of patients with radiation-refractory disease (n=33) and radio-responsive disease (n=43), median survival was 3.12 and 5.94 months, respectively (HR: 0.43 [95% CI: 0.26-0.70]). Among patients with radiation-refractory disease, 12 received chemotherapy after radiation, and two received erlotinib. Systemic therapy was associated with improved symptoms in two patients but did not appear to improve survival. Non-small cell lung cancer patients with radiation-refractory brain metastases represent a small subgroup who have a short survival and who appear to derive minimal benefit from systemic cancer therapy.

Occupational toxic epidermal necrolysis associated with dalbergia cochinchinensis: a retrospective comparative study of eight cases in China

Occupational toxic epidermal necrolysis (TEN) related to Dalbergia cochinchinensis has seldom been reported in the past. Its clinical characteristic needs to be investigated. This study reports eight cases of such disease in China. Eight patients with occupational TEN admitted from 2003 to 2012 were retrospectively analyzed and compared with 15 patients admitted with TEN caused by drugs as controls. Patients all received combination therapy of corticosteroid and intravenous immunoglobulin. The times for bullous ceasing, tapering of corticosteroid, and total hospitalization were compared between the two groups of patients. SCORTEN, a severity-of-illness scoring system for TEN prognosis, was applied to evaluate clinical outcome. The three time measurements in occupational TEN were longer than those in control, and the differences were statistically significant (P = 0.0023, 0.026, 0.0017), which means the total dose of corticosteroid needed in occupational TEN was higher than that in the control. There were no deaths in the two groups, although expected deaths were 0.612 and 0.836, respectively. Occupational TEN has a longer progression than TEN caused by drugs, and there is more difficulty in its treatment. Clinicians should pay attention to this disease. However, its mechanism and target therapy remain unclear.

Corticosteroid sensitivity in gliomatosis cerebri delays diagnosis

Gliomatosis cerebri is a rare malignant tumour originating from cerebral glial cells. Most experts currently view gliomatosis cerebri as a pattern of extensive glioma infiltration encompassing at least three cerebral...

Abatacept in the Treatment of Severe, Longstanding, and Refractory Uveitis Associated with Juvenile Idiopathic Arthritis

Abatacept (ABA), a selective T cell costimulation modulator that binds to CD80 and CD86 on antigen-presenting cells, was investigated for its antiinflammatory effect in treating severe chronic uveitis associated with juvenile idiopathic arthritis (JIA). Our retrospective study was conducted by members of the Multinational Interdisciplinary Working Group for Uveitis in Childhood (MIWGUC). Patients with JIA who are receiving ABA treatment for active uveitis were included. In all patients, uveitis had been refractory to previous topical and systemic corticosteroids, immunosuppressives, and at least 1 tumor necrosis factor-α inhibitor. A standardized protocol was used to document uveitis (MIWGUC) and arthritis. Baseline visit and visits at 3, 6, 9, and 12 months before and after ABA start were evaluated. Primary outcome measure was defined as achievement of uveitis inactivity; secondary outcome measures were tapering of corticosteroid and/or immunosuppressive treatment, and occurrence of complications. In all, 21 patients (16 female) with active uveitis (n = 21) and arthritis (n = 18) were included (mean age 11.8 ± 3.6 yrs). In 7 of 18 patients with active arthritis at baseline, inactivity was achieved following ABA treatment. Uveitis inactivity was achieved in 11 patients, but recurred later in 8 of them, and remained active in another 10 cases. Systemic corticosteroids or immunosuppression were tapered in 3 patients, but uveitis recurred in all of them during further followup. Ocular complications secondary to uveitis were present in 17 patients at baseline, while 3 patients developed new ocular complications during followup. A sustained response to ABA was uncommon in patients with severe and refractory uveitis.

Clinical trials in noninfectious uveitis.

Kim, Jane S. BS; Knickelbein, Jared E. MD, PhD; Nussenblatt, Robert B. MD, MPH; Sen, H. Nida MD, MHS Author Information

Efficacy of Adalimumab in a Girl with Refractory Intestinal Behcet's Disease.

We describe our experience with a juvenile patient who had refractory intestinal Behcet's disease that responded to adalimumab, a fully humanized antibody against soluble TNF-α and its receptor. The patient, a 13-year-old girl, presented with oral aphthous ulcers, vulvar pain, and rashes on the lower extremities. She gradually developed a low-grade fever, abdominal pain, diarrhea, and hematochezia. Lower gastrointestinal endoscopy revealed ulcers in the terminal ileum, consistent with intestinal Behcet's disease. Methylprednisolone pulse therapy was initiated, after which the symptoms transiently improved, but, during the corticosteroid taper, the abdominal pain recurred. The symptoms resolved soon after the administration of adalimumab. Of importance, the dose of corticosteroids was successfully reduced without exacerbation during 8 months of observation. This is the first reported case in which adalimumab was used for pediatric gastrointestinal Behcet's disease. Adalimumab is a good choice for intestinal Behcet's disease refractory to conventional treatment.

Is statin exposure associated with occurrence or better outcome in giant cell arteritis? Results from a French population-based study.

To investigate the potential association between statin use and giant cell arteritis (GCA) course. Using the French National Health Insurance system, we included patients with incident GCA from the Midi-Pyrenees region, southern France, from January 2005 to December 2008 and randomly selected 6 controls matched by age, sex, and date of diagnosis. Statin exposure was compared between patients with GCA and their controls before GCA occurrence with a logistic regression. Influence of statin exposure on prednisone requirements during GCA course was explored with a Cox model, considering statin exposure as a time-varying variable. The cohort included 103 patients (80 women, mean age 74.8 ± 9 yrs, mean followup 48.9 ± 14.8 mos), compared to 606 controls. Statin exposure (27.2% of patients with GCA and 23.4% of controls) was not associated with GCA occurrence (adjusted OR 1.2, 95% CI 0.76-1.96; p = 0.41). Diabetes mellitus was significantly associated to GCA occurrence (adjusted OR 0.38, 95% CI 0.11-0.72; p = 0.008). After diagnosis, exposure to statins up to 20 months was associated with maintenance while taking low prednisone doses (p = 0.01). Statin exposure was not associated with GCA occurrence in the general population. However, exposure to statins up to 20 months may favor a quicker corticosteroid tapering. Based on those results, statin effect on GCA course should not be definitively ruled out.

P007 - A case of acute disseminated encephalomyelitis mimicking multiple sclerosis attack treated by plasmapheresis

Acute disseminated encephalomyelitis (ADEM) is an acute multifocal demyelinating disease of the central nervous system. Its clinical course in most cases is monophasic; however, relapsing ADEM is rarely seen, which poses a diagnostic challenge for distinguishing this disease from multiple sclerosis (MS). The common treatment approach in ADEM consists of high daily doses of intravenous methylprednisolone for 3–5 days, followed by an oral corticosteroid taper. However, some patients with ADEM are refractory to steroid therapy. In case of insufficient response to corticosteroids, intravenous immunoglobulin G is a therapeutic option. Plasmapheresis might be an effective treatment and life-saving in cases of fulminant ADEM. We report a case of a 22-year-old man admitted to our clinic as a MS attack but lately suffering from fulminant ADEM. The patient did not respond to corticosteroid therapy but exhibited a dramatic recovery with plasmapheresis. Effectiveness of plasmapheresis has been demonstrated by previous case reports. For severe or life-threatening cases of ADEM, plasmapheresis should be considered early in the disease course. Acute disseminated encephalomyelitis (ADEM) is an acute multifocal demyelinating disease of the central nervous system. Its clinical course in most cases is monophasic; however, relapsing ADEM is rarely seen, which poses a diagnostic challenge for distinguishing this disease from multiple sclerosis (MS). The common treatment approach in ADEM consists of high daily doses of intravenous methylprednisolone for 3–5 days, followed by an oral corticosteroid taper. However, some patients with ADEM are refractory to steroid therapy. In case of insufficient response to corticosteroids, intravenous immunoglobulin G is a therapeutic option. Plasmapheresis might be an effective treatment and life-saving in cases of fulminant ADEM. We report a case of a 22-year-old man admitted to our clinic as a MS attack but lately suffering from fulminant ADEM. The patient did not respond to corticosteroid therapy but exhibited a dramatic recovery with plasmapheresis. Effectiveness of plasmapheresis has been demonstrated by previous case reports. For severe or life-threatening cases of ADEM, plasmapheresis should be considered early in the disease course.

Management Challenges in Crohn’s Disease With History of Acute Myeloid Leukemia

Introduction: In recent years, biologic and immunomodulator therapy has become a vital therapeutic option for managing inflammatory bowel disease. However, the therapy can become problematic when used for a prolonged period. Immune-suppression places patients at high risk for hematologic malignancies and can develop years after maintenance therapy. The challenge then becomes managing concomitant diseases. The literature to date does not offer recommendations on optimum management therapy modalities. Here, we present a case of a patient with recent history of acute myeloid leukemia (AML) and active Crohn’s disease. Case Report: A 62-year-old male presented to the oncology clinic for routine follow-up and Crohn’s therapy recommendations, particularly with infliximab use. The patient has a history of FLT-3 AML with normal cytogenetics and positive NPM1 mutation diagnosed in 2011, currently in remission. The patient has active moderate Crohn’s disease with perirectal fistulas, and recent fistulotomy with seton placement and on corticosteroid taper. The patient was diagnosed with Crohn’s in 2005, and required colonic resection with his last flare prior to his present presentation at the ileocolonic anastomosis. He was on oral 5-aminosalicylates, but due to the severity of his disease, was started on infliximab maintenance therapy prior to his diagnosis of AML. His AML was treated with high-dose daunorubicin and cytarabine with complete remission, and then received 4 cycles of high-dose cytarabine consolidation. Bone marrow done in December 2012 showed complete remission. The patient was started on 6-mercaptopurine for maintenance, but was discontinued after a repeat bone marrow done on July 2013 showed mild dysplastic changes with 3% ringed sideroblasts and no evidence of AML relapse. The patient’s gastroenterologist was advised to continue steroid therapy and not be started on immunomodulator or biologic therapy for maintenance and consider reintroducing oral 5-aminosalicylates. Discussion: The theoretical concern of infliximab therapy, which uses T-cell immunosuppression modality, may increase the risk of relapse of his acute leukemia. The American College of Gastroenterology does not advise the use of systemic steroid therapy or budesonide for maintenance Crohn’s therapy. However, given the incomplete literature with AML and concomitant Crohn’s disease, it was decided prolonged steroid therapy was the most beneficial treatment option. The recurrence of his AML posed a greater concern than corticosteroid induced side effects. Treating clinicians need to weigh the risks and benefits with each treatment modality when guidelines are limited to the course of management.