A 43-year-old woman sought care for bilateral lower limb numbness and paresthesias accompanied by a tight, bandlike sensation around her torso at the mid chest level. She had an episode 4 months earlier of bilateral arm paresthesias. The right arm paresthesias lasted several hours, but the left arm paresthesias persisted for 1 week. Urinary frequency had recently developed, but no incontinence. She had no associated limb weakness, facial numbness or weakness, or vision loss. Magnetic resonance imaging of the cervical spine showed multiple, short-segment, T2-hyperintense lesions. C1 and C4-5 lesions demonstrated contrast enhancement. Magnetic resonance imaging of the brain showed multiple ovoid areas of T2 hyperintensity involving the periventricular regions. Postcontrast images indicated 2 contrast-enhancing lesions adjacent to the posterior aspect of the right lateral ventricle. Magnetic resonance imaging of the thoracic spine showed several T2-hyperintense lesions without contrast enhancement. Vitamin B12 level was low. Cerebrospinal fluid analysis revealed 1 nucleated cell/µL, protein concentration of 85 mg/dL, and 17 cerebrospinal fluid -exclusive oligoclonal bands. Testing for JC polyoma virus was negative in the cerebrospinal fluid by polymerase chain reaction, but serologic results were positive. The patient was diagnosed with central nervous system demyelination in association with Crohn disease and tumor necrosis factor-α inhibitor use. The patient discontinued adalimumab and started vedolizumab (α4β7 integrin inhibitor) for her Crohn disease. Magnetic resonance imaging of the brain and cervical spine 3 months after the therapy changes showed 2 new periventricular lesions in the temporal lobes without contrast enhancement. Magnetic resonance imaging of the cervical spine was stable. Because of her seropositivity to JC polyoma virus and history of immunosuppression, natalizumab (α4β1 and α4β7 integrin inhibitor) was not recommended. After discussion regarding therapy choice, the patient elected to start fingolimod. Inflammatory bowel and connective tissue diseases are commonly treated with immunosuppressants including tumor necrosis factor-α inhibitors. Tumor necrosis factor-α is a cytokine with a wide range of functions, including immune cell regulation, induction of the inflammatory response, inhibition of tumor growth, and induction of apoptosis.
Current management of fistulizing perianal Crohn’s disease based on serum anti-tumor necrosis factor levels and magnetic resonance imaging monitoring
