Hodgkin Lymphoma Following Adalimumab for the Treatment of Crohn’s Disease in an Adolescent

Excerpt

An 11-year-old previously healthy girl was initially referred to the pediatric gastroenterology clinic at Stanford because of persistent fever, abdominal pain and hematochezia. Her physical examination was normal. Laboratory studies showed mild anemia (hemoglobin 10.7 g/dL), an increased erythrocyte sedimentation rate (ESR) of 46 and a positive Epstein–Barr virus (EBV) IgM antibody. Diagnosed with infectious mononucleosis, she was treated supportively with oral fluids and antipyretics. Due to persistent symptoms with persistent anemia, increased ESR (55) and decreased albumin (2.3), the diagnosis of inflammatory bowel disease (IBD) was considered and evaluated with upper endoscopy, which revealed normal-appearing esophagus, stomach and duodenum, whereas friability and extensive exudates were present throughout the colon with prominent lymphoid hyperplasia and friable mucosa in the terminal ileum. Acute ileitis with granulomas and ulcerations, consistent with Crohn’s disease, was present in the biopsies. Based on a presumptive diagnosis of Crohn’s disease, induction therapy with mesalamine, prednisone and 6-mercaptopurine (6-MP) was initiated. Allopurinol was added later due to persistent increased concentrations of the putative toxic serum 6-MP metabolite 6 methyl mercaptopurine (6-MMP) [1]. Over the course of 2 years, she had multiple flares despite therapeutic serum concentrations of the 6-thioguanine (6-TGN) concentrations requiring frequent courses of high-dose corticosteroids. Due to poor disease control and steroid dependence, she was switched to adalimumab monotherapy. Shortly after starting adalimumab, she was no longer having abdominal pain; 5 months after switching, her anemia resolved, albumin improved (4.0) and ESR normalized. …