Pulmonary cryptococcosis in a patient with Crohn's disease treated with prednisone, azathioprine and adalimumab: exposure to chicken manure as a source of contamination.
BACKGROUND
Biotherapies targeting TNFα were proven to be effective in the most severe cases of Crohn's Disease, a chronic granulomatous inflammatory bowel disease that can involve any portion of the digestive tract. The tolerance of anti-TNFα therapy is usually good, although several infectious complications have been reported with these drugs.


METHODS
We report a case of a Crohn's disease patient who developed pulmonary cryptococcosis following chicken manure exposition while he received adalimumab and azathioprine.


METHODS
A 54-year-old man, with history of severe Crohn's disease and ankylosing spondylitis, was admitted for diarrhea and abdominal pain under azathioprine treatment. In December 2010, he was treated with oral prednisone (1 mg/kg/day), but Crohn's disease relapsed when prednisone dose was lower than 30 mg/a day. The patient was then treated with adalimumab, but six weeks later he developed severe pulmonary cryptococcosis. The patient experienced a good outcome under antifungal therapy. We retrospectively found a high exposure to chicken manure in the last weeks.


CONCLUSIONS
Cryptococcosis is an opportunistic infection that can occur under anti-TNFα therapy. The environmental exposure to Cryptococcus spp. (in particular in chicken manure) is a source of contamination. Avoiding exposition to bird manure should be a recommendation for patients who are living in rural areas.
Université Montpellier 1, Service de Médecine Interne A, Hôpital Saint-Eloi, 80 avenue Augustin Fliche, 34295 Montpellier Cedex 5, France.
Jean-Baptiste
JB
Fraison
Philippe
P
Guilpain
Aurélie
A
Schiffmann
Michel
M
Veyrac
Vincent
V
Le Moing
Philippe
P
Rispail
Alain
A
Le Quellec
D000068879:Adalimumab; D000818:Animals; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D001379:Azathioprine / Q000627:therapeutic use; D002645:Chickens; D003424:Crohn Disease / Q000150:complications / Q000188:drug therapy*; D003453:Cryptococcosis / Q000150:complications / Q000188:drug therapy / Q000382:microbiology*; D004781:Environmental Exposure / Q000009:adverse effects*; D005243:Feces / Q000382:microbiology*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D008172:Lung Diseases, Fungal / Q000188:drug therapy / Q000382:microbiology*; D008297:Male; D008875:Middle Aged; D011241:Prednisone / Q000627:therapeutic use
D000893:Anti-Inflammatory Agents; D061067:Antibodies, Monoclonal, Humanized; D000935:Antifungal Agents; D007166:Immunosuppressive Agents; D000068879:Adalimumab; D001379:Azathioprine; D011241:Prednisone