Infliximab to Treat Crohn'S-like Inflammatory Bowel Disease in Chronic Granulomatous Disease
Infliximab to Treat Crohn'S-like Inflammatory Bowel Disease in Chronic Granulomatous Disease
This study will determine if the drug infliximab is safe for treating inflammatory bowel
 disease (IBD) in patients with chronic granulomatous disease (CGD). IBD is an inflammation or
 irritation of the gut that leads to symptoms such as diarrhea, bloating and stomach cramps.
 CGD is an inherited disease affecting white blood cells called neutrophils in which patients
 are susceptible to repeated bacterial and fungal infections. They also have a higher
 incidence of some autoimmune diseases, such as IBD. Infliximab is approved to treat Crohn's
 disease, an IBD similar to that seen in patients with CGD.

 Patients 10 years of age and older with CGD and IBD may be eligible for this study.
 Candidates are screened with a medical history, physical examination, blood and urine tests,
 electrocardiogram (EKG), tuberculosis skin test (PPD skin testing), and stool test for the
 presence of infections. Additional tests may be done, including colonoscopy (procedure using
 a flexible tube through the rectum to examine the lining of the gut) and imaging studies such
 as an x-ray, chest CT scan (test using a special x-ray machine), MRI (test using a magnetic
 field and radio waves), and barium studies (study using a drinkable solution of barium to
 help enhance the x-ray pictures of the gut).

 Participants are divided into patients with IBD symptoms (Group 1) and patients without IBD
 symptoms (Group 2) for the following procedures:

 Group 1

 Patients are evaluated every 6 months with a medical history and physical examination for
 signs and symptoms of IBD. Patients who are taking moderate to high doses of steroid
 medications have their medication slowly lowered (tapered) and are evaluated every 3 months
 for a total of 2 years. Patients in this group who start to develop IBD symptoms are moved to
 Group 2 for treatment with infliximab (see below).

 Group 2

 Patients in Group 2 receive infliximab infusions at 2-week intervals for three doses. The
 drug is given over a 2-hour period through a catheter placed in a vein. Patients are
 evaluated with a medical history, physical exam, and blood tests the day of each dose. One
 week after the last dose, they have another evaluation, including a colonoscopy. Patients who
 respond well to infliximab may continue to receive the drug every 2 months for a total of 1
 year, with evaluations at every dosing visit. At the end of the first year of receiving
 infliximab, all patients have follow-up evaluations every 6 months for a total of 2 years.

 Group 3

 Subjects who volunteer to undergo colonoscopy and research biopsies that serve as controls
 for evaluation of the patient gut samples.
Chronic Granulomatous Disease (CGD) is an inherited immune disorder involving decreased
 phagocytic superoxide oxygen radical production, resulting in increased susceptibility to
 infections. Furthermore, there is a predominance of immune-related inflammatory problems in a
 subset of CGD patients, such as the inflammatory bowel disease (CGD-IBD). CGD-IBD is often
 complicated by obstruction, strictures, fissures, fistulae, and extra-intestinal problems. In
 fact, it is clinically and histologically indistinguishable from Crohn's Disease (CD),
 another inflammatory bowel disease that affects the general population. Crohn's disease (CD)
 is a prototypic T helper cell type 1 (Th1) immune disease. Since CGD-IBD bears such close
 resemblance to CD, it is possible that CGD-IBD is also immune-based. Furthermore, mice
 studies also support a primarily immune basis for CGD-IBD. However, currently there is little
 data on this Crohn's-like CGD-IBD in human patients. Treatment for the Crohn's-like CGD-IBD
 has been primarily oral or topical corticosteroids. Antibiotics have been ineffective and
 stool cultures typically do not identify clear pathogens. Many patients with the Crohn's-like
 CGD-IBD disease remain steroid-dependent, thus new therapeutic regimens are needed.

 This is a Phase I/II study that will evaluate the safety and efficacy of Tumor Necrosis
 Factor Alpha Inhibitor (Infliximab or Adalimumab) in CGD patients with symptomatic
 Crohn's-like IBD. Infliximab and Adalimumab are standard-of-care treatments for moderate to
 severe CD, with extensive experience using these agents being well documented in terms of
 safety and efficacy. Preliminary reports from ongoing studies of CD at NIH are encouraging in
 inducing remission. We will also evaluate changes in immunophenotype and cytokine profiles of
 peripheral blood and colonic lamina propria lymphocytes following treatment. In addition, we
 will evaluate the immunophenotype and cytokine profile of blood and mucosal cells in CGD
 patients, with or without IBD, to determine the CGD-specific cytokine profile. Specific
 cytokine profiles have been observed in different genetic immunodeficiencies, despite similar
 IBD clinical manifestation.

 Documentation of clinical status will be performed using the Crohn's Disease Activity Index
 (CDAI). Potential effects of genetic variation (including CGD mutation type) on the
 expression of IBD in patients with CGD, and their responses to treatment will also be
 assessed. The long-term goal of this study is to establish better or alternative treatment
 modalities with low risk profiles for CGD patients with Crohn's-like IBD.
-  INCLUSION CRITERIA:

 Group One

 -  Must have a confirmed CGD diagnosis

 -  Must have IBD documented by medical history or documented IBD endoscopically.

 -  Must not be pregnant or breastfeeding

 -  Must have a home physician

 -  Must be willing to submit samples for storage.

 Group Two:

 -  Must have a confirmed CGD diagnosis

 -  Must have IBD documented by medical history or documented IBD endoscopically.

 -  Must be symptomatic

 -  Must have negative results on stool examination for culture of enteric pathogens, such
 as Salmonella, Shigella, Yersinia, Campylobacter, E. coli O157/H7, Clostridium
 difficile toxin assay, enteric parasites and their ova such as Cryptosporidia,
 Cyclospora, Microsporidia and Giardia (by stool enzyme immunoassay [EIA]) prior to the
 start of receiving TNF? inhibitors.

 -  Must not be pregnant or breastfeeding

 -  If of childbearing potential, one must agree to consistently use contraception, while
 on the study medication.

 -  Must have a recent chest CT (within 3 months) to confirm absence of tuberculosis (TB)
 infection

 -  Must have a home physician

 -  Must be willing to submit samples for storage.

 Group Three:

 -  Must be willing to undergo upper and lower endoscopy and mucosal biopsies for research
 purpose

 -  Must be greater than or equal to 18 years old and weigh greater than or equal to 15
 kg.

 -  Must not be pregnant

 -  Must be willing to submit samples for storage.

 EXCLUSION CRITERIA:

 Group One:

 - Any condition that, in the investigator's opinion, places the patient at undue risk by
 participating in the study.

 Group Two:

 -  Any condition that, in the investigator's opinion, places the patient at undue risk by
 participating in the study

 -  Positive TB diagnosis

 -  Patients who are in the at-risk group for treatment such as history of tuberculosis,
 congestive cardiac failure or myocardial infarction within the last 12 months unstable
 angina, thrombocytopenia (platelet < 100, 000), uncontrolled hypertension

 -  Acute systemic or intestinal infection(s)

 -  Evidence of Hepatitis B or C infection

 -  Signs and symptoms of hepatotoxicity

 -  Pregnant or breastfeeding

 -  History of cancer within the last 10 years

 -  The presence of certain types of acquired abnormalities of immunity such as HIV,
 cytotoxic chemotherapy for malignancy could be grounds for possible exclusion if, in
 the opinion of the investigator, the presence of such disease process interferes with
 evaluation of a co-existing abnormality of immunity that is a subject of study under
 this protocol.

 -  Co-existing Th2-type inflammatory disease

 -  Current active bowel obstruction, intestinal perforation, or significant GI
 hemorrhage.

 -  Live vaccine within 4 weeks prior to therapy or potential need for a live vaccine
 during the study.

 -  Unwillingness to undergo testing or procedures associated with this protocol.

 Group Three:

 -  Acute systemic or intestinal infection requiring antibiotics

 -  Any condition that, in the investigator's opinion, places the patient at undue risk by
 participating in the study

 -  The presence of certain types of acquired abnormalities of immunity such as HIV,
 cytotoxic chemotherapy for malignancy could be grounds for possible exclusion if, in
 the opinion of the investigator, the presence of such disease process interferes with
 evaluation of a co-existing abnormality of immunity that is a subject of study under
 this protocol.

 -  Unwillingness to undergo testing or procedures associated with this protocol.