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Case Reports
. 2001:1:8.
doi: 10.1186/1471-230x-1-8. Epub 2001 Aug 29.

Is it Crohn's disease? A severe systemic granulomatous reaction to sulfasalazine in patient with rheumatoid arthritis

L G Quallich  1 , J Greenson, H M Haftel, R J Fontana
Affiliations
Case Reports

Is it Crohn's disease? A severe systemic granulomatous reaction to sulfasalazine in patient with rheumatoid arthritis

L G Quallich et al. BMC Gastroenterol. 2001.

Abstract

Background: Sulfasalazine is a widely used anti-inflammatory agent in the treatment of inflammatory bowel disease and several rheumatological disorders. Although as many as 20% of treated patients may experience reversible, dose-dependent side effects, less frequent but potentially severe, systemic reactions have also been reported.

Case presentation: A severe systemic reaction to sulfasalazine developed in a 21-year old female with rheumatoid arthritis characterized by eosinophilia, granulomatous enteritis and myelotoxicity, cholestatic hepatitis, and seizures. The clinical course and management of this patient are presented as well as a review of the incidence and outcome of severe systemic reactions to sulfasalazine.

Conclusions: Granulomatous myelotoxicity and enteritis developed in a 21 year old female within 3 weeks of initiating sulfasalazine for rheumatoid arthritis. Following a short course of corticosteroids, the patient had resolution of her cholestatic hepatitis, rash, eosinophilia, and gastrointestinal symptoms with no residual manifestations at 7 months follow-up. Although severe reactions to sulfasalazine are rare and unpredictable, practicing physicians should be aware of unusual clinical presentations of toxicity when prescribing sulfasalazine.

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Figures

Figure 1
Figure 1
A: Medium-power photomicrograph of the colon showing a small epithelioid granuloma (arrow) (Hematoxylin and eosin stain. B: Low-power photomicrograph of bone marrow showing a hypercellular marrow with an epithelioid granuloma (arrow) (Hematoxylin and eosin stain).
Figure 2
Figure 2
Liver biochemical profile. The patient had a normal serum alkaline phosphatase and bilirubin level 14 days prior to presentation. The marked intrahepatic cholestasis did not improve until initiation of steroids on day #14. At post-discharge follow-up on day #40, both the serum alkaline phosphatase and bilirubin had normalized. * = Upper limit of normal
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