Case Presentation

1
Case Presentation

• 34 y/o male
• 5 years Crohns disease of ileum and Rt. colon
• 10 days Fever, chills
• Watery diarrhea
• RLQ abdominal pain

2
Medical History

• 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
• HE Inclusion body

Kishore et al. J med microbiol 200453
9
Kishore et al. J med microbiol 200453
10
ILEOCECAL VALVE
11
HE STAINING
12
?
13
Diagnosis IHC vs HE
Kambham et al. Am J Surg pathol 2004 283
14
Diagnosis IHC vs HE
Kambham et al. Am J Surg pathol 2004 283
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 Crohns
  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 200453

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 967
• Kambham et al. Am J Surg pathol 2004 283

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?