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Old 01-02-2017
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Star New case: Patient with Crohn disease

Hi all,

A 68-year-old woman with a 39-year history of Crohn disease had been treated with a stable dose of MTX (25 mg/wk), along with folic acid, for approximately 13 years. In response to abdominal pain and an increased frequency of bowel moments, oral prednisone was initiated at a recent hospital admission for what clinically appeared to represent a Crohn disease exacerbation. The patient was also prescribed TMP-SMX (combination of 160 mg of TMP, 800 mg of SMX 3 times weekly) for P jiroveci pneumonia prophylaxis while taking corticosteroids. The patient was discharged with a tapering dose of prednisone, and over the following weeks as an outpatient, her abdominal pain progressed and her diarrhea worsened; she was also unable to ingest solid food owing to nausea, vomiting, and extremely painful mouth sores.
Three weeks after initial discharge, she presented to hospital with dehydration and painful stomatitis (Figure 1). Her medications at the time of admission were as follows: 25 mg of MTX intramuscularly weekly; 160/800 mg of TMP-SMX 3 times weekly; 15 mg of prednisone daily; 1 mg of folic acid daily; 10 mg of alendronate daily; and 1000 IU of vitamin D daily. On admission, her bloodwork results revealed the following: a serum creatinine level of 184 μmol/L; a white blood cell count of 1.3 109/L; a hemoglobin level of 71 g/L (mean corpuscular volume of 80.4 fL); and a platelet concentration of 115 109/L. The patient was treated with intravenous (IV) fluid for rehydration, oral nystatin for a presumptive diagnosis of oral candidiasis, and IV morphine for mouth pain. Consultation with a hematologist.

Question 1: Why is Methoxtrixane and TMP-SMX therapy stopped and antagonized with Folic acide (Vit B9) and Prednisone carried on?
Knowing that
- Buccal swabs were negative for Candida, while a lip swab later grew herpes simplex in culture.
- Was treated for stomatitis.

Thanks for explaining the clear pharmacology behind this and suggesting any other possible management for Stomatits.
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