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Case Presentation

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.

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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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