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Case Presentation

A 34-year-old male with a 5-year history of Crohn’s disease experiences fever, chills, and watery diarrhea for 10 days alongside right lower quadrant (RLQ) abdominal pain. His past treatment included azathioprine. Clinical examination shows fever and RLQ tenderness, but no hepatosplenomegaly. Despite initial management with metronidazole and IV hydrocortisone, there was no improvement. Testing reveals positive CMV IgM. The case highlights the complexities in diagnosing and managing CMV colitis within immunosuppressed patients, specifically those with inflammatory bowel disease.

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Case Presentation

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  1. 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

  2. MedicalHistory • Last exacerbation 6m ago • No surgical history • Treatment: Azathioprine 150 mg

  3. Physical Examination Fever –38.6, HR-90 Tenderness – RLQ , Without hepatosplenomegaly or ascitis PR- normal No lymphadenpathy Heart & lungs- normal

  4. 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

  5. Management Treatment 7 days with PO metronidazole and IV hydrocortisone – without improvement

  6. CMV IgG – negative • CMV IgM – positive • CMV antigenemia – negative

  7. NEXT STEP? CMV COLITIS AZATHIOPRINE HYDROCORTISONE START

  8. 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

  9. Kishore et al. J med microbiol 2004;53

  10. ILEOCECAL VALVE

  11. H&E STAINING

  12. ?

  13. Diagnosis IHC vs H&E Kambham et al. Am J Surg pathol 2004; 28:3

  14. Diagnosis IHC vs H&E Kambham et al. Am J Surg pathol 2004; 28:3

  15. CMV-IHC STAINIG

  16. CMV COLITIS • Defective cell-mediated immunity: • AIDS, organ transplant recipients, immunosuppression • Old age, cancer, CRF, alcoholism • Immunocompetent hosts : Mucosal damage

  17. 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

  18. 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

  19. CLINICAL CHARACTERISTICS • 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

  20. DIAGNOSIS • 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

  21. TREATMENT • Gancyclovir • 5 mg/kg bid • 6 weeks of intravenous treatment • Marked improvement usually noted within a week

  22. TREATMENT STOP! • Steroids (rapid tapering) • Cyclosporin • Azathioprine • 6-MP

  23. IMMUNOSUPPRESSION THERAPY RENEWAL?

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