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Rationale: Latent tuberculosis (TB) infection screening before inducing anti-tumor necrosis factor (anti-TNF) alpha agents is important to prevent TB reactivation. However, latent TB infection reactivation may still occur, and the ideal therapeutic strategy for patients with inflammatory bowel disease (IBD) who develop active TB infection has not been established. Vedolizumab (VDZ) has a good safety profile, with low incidence rates of serious infections. However, its safety in patients with latent TB infection reactivation associated with anti-TNF-alpha agents remains unknown. Patient concerns: A 21-year-old Vietnamese male patient presented to our hospital with hemorrhagic stool. He had no personal or family history of IBD or TB. Diagnoses: Colonoscopy revealed multiple longitudinal ulcers and a cobblestone appearance in the terminal ileum, as well as multiple small erosions and aphtha throughout the colon. Computed tomography revealed a right lung nodular lesion. Serological interferon-gamma release assay and several culture tests were all negative. Thus, he was diagnosed with ileocolonic Crohn’s disease (CD) without TB. Interventions: The intravenous anti-TNF-alpha agent administration with an immunomodulator was initiated. Outcomes: Computed tomography revealed nodular lesion expansion at the right lung, and serological interferon-gamma release assay was positive. He was diagnosed with latent TB infection reactivation. Anti-TNF-alpha agent with an immunomodulator was immediately discontinued, and anti-TB therapy was initiated. His endoscopic findings were still active, and VDZ was selected for maintenance therapy because VDZ has a favorable safety profile with low incidence rates of serious infections. Consequently, mucosal healing was achieved without active TB relapse. Lessons: This case report presented a patient in whom VDZ was continued as maintenance therapy without inducing TB relapse in a patient with CD who developed latent TB infection reactivation associated with anti-TNF-alpha agents and summarized the safety profile of VDZ for patients with IBD with active or latent TB infection. VDZ may be a safe option for induction and maintenance therapy in patients with CD, even in cases with latent TB infection reactivation.

Background and study aims: Transnasal endoscopy presents a technical difficulty when inserting the flexible endoscope, and it is unclear whether a particular breathing method is useful for transnasal endoscopy. Therefore, we conducted a prospective randomized controlled trial to compare endoscopic operability and patient tolerance between patients in the nasal breathing and oral breathing groups. Patients and methods: A total of 198 eligible patients were randomly assigned to undergo the transnasal endoscopy with nasal breathing and with oral breathing. Endoscopists and patients answered questionnaires on the endoscopic operability and patient tolerance using a 100-mm visual analog scale ranging from 0 (non-existent) to 100 (most difficult/ unbearable). The visibility of the upper-middle pharynx was recorded. Results: Patient characteristics didn’t differ significantly in both groups. Nasal breathing showed a higher rate of good visibility of the upper-middle pharynx than oral breathing (91.9% vs. 27.6%; p<0.05). Nasal breathing showed lower scores than oral breathing in overall technical difficulty (21.0±11.4 vs. 35.4±15.0; p<0.05). Regarding patient tolerance, nasal breathing showed lower scores than oral breathing in overall discomfort (22.1±18.8 vs. 30.5±20.9; p<0.05) and other symptoms, including nasal and throat pain, choking, suffocating, gagging, belching, and bloating (p<0.05). Pharyngeal bleeding rate was lower in the nasal breathing group than that in the oral breathing group (0% vs. 9.2%; p<0.05). Conclusions: Nasal breathing is superior to oral breathing in performing and undergoing transnasal endoscopy. Nasal breathing led to good visibility of the upper-middle pharynx, improved endoscopic operability and patient tolerance, and showed safety by decreasing pharyngeal bleeding.

Background: Screening of latent tuberculosis (TB) before the induction of anti-tumor necrosis factor (anti-TNF) agents is very important to prevent the reactivation of TB. However, active TB can still occur, and the ideal therapeutic strategy for IBD patients who develop active TB has not been established. Case presentation: A 21-year-old Vietnamese man with active ileo-colonic Crohn’s disease visited our hospital. While computed tomography (CT) revealed a nodular lesion at the right lung, a serological interferon gamma release assay (IGRA) and several culture tests were all negative. The intravenous administration of infliximab-biosimilar (IFX-BS) with an immunomodulator were initiated. After the induction therapy, he achieved clinical remission. However, he presented with a high fever 17 weeks after the initiation. CT revealed the expansion of the nodular lesion at the right lung, and serological IGRA was positive. He was diagnosed with reactivation of latent TB. He had not achieved mucosal healing when immunosuppressive therapy was discontinued. Thus, he was administered vedolizumab (VDZ), which was considered not to influence the TB status, as maintenance therapy. Consequently, he achieved mucosal healing without relapse of active TB.Conclusions: This is the first report to describe the safe usage of VDZ as maintenance therapy without the induction of TB relapse in a CD patient. In Asian countries, clinicians must be alert for the reactivation of latent TB during the administration of anti-TNF agents. VDZ might be a safe option for maintenance therapy in CD patients, even in cases with active TB.