to Ceftriaxone 2g every 12 hours. On hospital day #8, the patient underwent tricuspid valve replacement with a mechanical valve. He was discharged on hospital day #14 with plans to complete a 6-week course of ceftriaxone. His course was later complicated by a pericardial effusion and supratherapeutic INR requiring emergent pericardiocentesis. enner Medical Center (OKMC), LSUHSC internal medicine had four medicine ward teams with one resident and one intern each took call every four days. There were two night float interns who rotated every three days. We also had five other house officers on consult rotations. DISCUSSION Gonococcal Endocarditis will inherently become increasingly common due to rising cases of gonorrhea STIs and antibiotic resistance. Identification of genitourinary infections and early effective treatment is imperative to prevent serious sequelae. In this case, genitourinary manipulation for treatment of nephrolithiasis in the setting of active gonococcal infection was likely the nidus of hematogenous spread. ■ RESOLUTION OF METASTATIC CROHN’S DISEASE AFTER TREATMENT WITH CERTOLIZUMAB V Bolgiano, DO, D Cohen MD, S Walker MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION Crohn’s disease (CD) is a chronic inflammatory bowel disease (IBD) which may have distinctive mucocutaneous manifestations. Up to 33% of IBD patients have at least one extraintestinal disease manifestation. To our knowledge, this is the first case to describe success in treating MCD with certolizumab alone. CASE A 63-year-old woman with a previous history of Crohn’s disease presented to the dermatology clinic for evaluation of a rash located on her right upper lip. She reported that the rash appeared two years prior. It was associated with pruritus andmoderate swelling. Histopathological findings from a 4.0 mm punch biopsy revealed multiple nodular
granulomatous infiltrates extending from the superficial reticular to deep reticular dermis. The granulomas were composed of numerous histiocytes as well as a moderately dense inflammatory infiltrate made up predominantly of lymphocytes with scattered plasma cells and eosinophils. S-100 staining was negative. PAS and Fite stains were negative for infectious organisms. The patient had tried Humira, Imuran, Remicade, Plaquenil, Minocycline, and intralesional Kenalog with minimal improvements. This patient ultimately responded to the induction dose of 400 mg certolizumab (2 injections of 200 mg) and was prescribed a maintenance dose of 400 mg every other week that will require long-term follow up. DISCUSSION Metastatic Crohn’s disease is a rare, non-contiguous cutaneous manifestation of primary CD, being the least common presentation of extra-intestinal CD. Most cases of MCD occur on the lower extremities, intertriginous areas, face, and genital area. No clear correlation between the development of MCD and luminal disease activity has been established. Adalimumab, infliximab, antibiotics, systemic & topical corticosteroids, methotrexate, and azathioprine have demonstrated benefit in MCD. Certolizumab (certolizumab pegol) is a PEGylated anti-tumor necrosis factor biologic therapy approved for use in Crohn’s disease among other diseases. ■
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