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Case Presentation
• 34 y/o male
• 5 years Crohn’s disease of ileum and Rt.
colon
• 10 days –
Fever, chills
Watery diarrhea
RLQ abdominal pain
Medical History
• Last exacerbation 6m ago
• No surgical history
• Treatment: Azathioprine 150 mg
Physical Examination
Fever –38.6, HR-90
Tenderness – RLQ , Without
hepatosplenomegaly or ascitis
PR- normal
No lymphadenpathy
Heart & lungs- normal
Laboratory Data
• Hb-11.5, MCV-81,WBC- 3400, Neu- 62%
PLT-197
• ALK.P, T Bill- normal, ALT-71, GGT- 110,
LDH-746
• Total Protein - 63 ,ALB - 29
• Folic acid, B12-normal
• Blood, urine , fecal culture , CDT -negative
Management
Treatment 7 days with PO metronidazole
and IV hydrocortisone – without
improvement
• CMV IgG – negative
• CMV IgM – positive
• CMV antigenemia – negative
NEXT STEP?
CMV COLITIS
AZATHIOPRINE
HYDROCORTISONE
START
CMV IgM?
• 63 patient –Active IBD
• Evaluated for CMV :
IgM CMV
PCR – Colonic biopsy
H&E – Inclusion body
Kishore et al. J med microbiol 2004;53
Kishore et al. J med microbiol 2004;53
ILEOCECAL VALVE
H&E STAINING
Diagnosis IHC vs H&E
Kambham et al. Am J Surg pathol 2004; 28:3
Diagnosis IHC vs H&E
Kambham et al. Am J Surg pathol 2004; 28:3
CMV-IHC STAINIG
CMV COLITIS
• Defective cell-mediated immunity:
• AIDS, organ transplant recipients,
immunosuppression
• Old age, cancer, CRF, alcoholism
• Immunocompetent hosts :
Mucosal damage
EPIDEMIOLOGY IN IBD
• More common in UC
- Prevalence: 4.6% in UC, 0.8% in Crohn’s
disease
- 12% of patients with intestinal CMV
infection
Kaufman et al. Dis Colon Rectum 1999; 42: 24
• Usually reactivation of latent virus
PREDISPOSING FACTORS
• Duration of IBD
• Active inflammation
• Treatment
- Steroids with other immunosuppression
Often in a patient who had long been
stable
Kishore et al. J med microbiol 2004;53
CLINICAL CHARACTERISTICS
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•
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Exacerbation of the underlying IBD
Mononucleosis-like syndrome
Steroid -refractory colitis
Additional GI manifestations – oral
lesions, odynopagia
Papadakis et al. Am J Gastroenetrolgy 2001; 96:7
Kambham et al. Am J Surg pathol 2004; 28:3
DIAGNOSIS
•
•
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Serology
CMV antigenemia
PCR for CMV
Endoscopic appearance
- Erosions, ulcerations, mucosal hemorrhage
• Mucosal biopsy
- Large cells with intranuclear and intracytoplasmic
inclusions
- Immunostaining
- Submucosal vasculitis or microvascular thrombosis
TREATMENT
• Gancyclovir
• 5 mg/kg bid
• 6 weeks of intravenous treatment
• Marked improvement usually noted within a week
TREATMENT
STOP!
•
•
•
•
Steroids (rapid tapering)
Cyclosporin
Azathioprine
6-MP
IMMUNOSUPPRESSION
THERAPY RENEWAL?