Mucosal Healing of Pediatric Simple Ulcer Treated With Infliximab and Methotrexate

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A large single ulcer of the colon can be difficult to differentiate as a separate entity (“simple ulcer” (1–3)) or as a manifestation of intestinal Behçet disease or Crohn disease (4). A 5-year-old boy, who had been diagnosed with steroid-dependent Crohn disease, was referred to our hospital. Colonoscopy revealed a giant oval-shaped punched-out ulceration in the ileocecal valve, typical of intestinal Behçet disease (1–4) (Fig. 1A). Histologic examination showed mild chronic inflammation. Esophagogastroduodenoscopy and capsule endoscopy revealed no specific findings, and he had no other findings such as ulcerative genital and inflammatory ocular lesions. Differential diagnoses including amebiasis, campylobacter, and cytomegalovirus were excluded by other tests (5). From the results, he was diagnosed with a single large ulcer (“simple ulcer”). Because of steroid dependence, infliximab was administered (6,7). His symptoms improved rapidly. After the fourth injection of infliximab, he relapsed. Infliximab dose was increased to 10 mg/kg, and methotrexate was added. Clinical steroid-free remission has been maintained for 3 years using the combination therapy of infliximab and methotrexate. Colonoscopy 3 years later revealed complete mucosal healing of the giant oval-shaped punched-out ulceration (Fig. 1B).FIGURE 1: Intestinal lesion in pediatric “simple ulcer.” A, Before infliximab; a typical giant oval-shaped punched-out ulceration in the ileocecal valve. B, 3 Years after infliximab; complete mucosal healing of an oval-shaped punched-out ulceration.

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