University of Texas Health Science Center at Houston Houston, TX, United States
Tanmay Gaglani, MD, Samantha Chung, MD, Rongying Li, MD, Joshua Balwaa, MD, PhD, Zhenjian Cai, MD, PhD, Scott Larson, MD, PhD University of Texas Health Science Center at Houston, Houston, TX
Introduction: Management of patients with inflammatory bowel disease (IBD) typically involves immunosuppression. While this can help achieve disease control, patients can become susceptible to rare infectious pathogens. These infections can present with symptoms similar to native IBD, complicating diagnostic accuracy.
Case Description/Methods: A 52 year old woman with a 11 year history of ulcerative colitis (UC) presented to the emergency room for evaluation of abdominal pain, diarrhea and hematochezia with a Mayo disease activity index (DAI) of 10/12. Previously the patient’s UC had been well controlled with mesalamine and azathioprine, but eventual escalation to adalimumab was required.
CT abdomen showed wall thickening, submucosal edema and wall enhancement in the entire colon and rectum. The patient was tested for Clostridium Difficile, enteric pathogens, and fecal leukocytes which were all negative. The patient was started on IV solumedrol and biologic therapy was escalated to infliximab loading dose with plans for 10mg/kg maintenance dosing for presumed UC flare. Symptoms of abdominal pain and diarrhea with hematochezia persisted.
Colonoscopy was conducted showing that the mucosa was diffusely erythematous with edema and deep ulcerations. Mucosal biopsies obtained revealed chronic active colitis with positive tissue immunohistochemistry testing for CMV and EBV seen in Figure 1. Ganciclovir was added to the steroid and infliximab regimen with significant reduction in abdominal pain, diarrhea and hematochezia with a resultant DAI of 3/12.
Discussion: CMV and EBV are herpes viruses that have been identified with increased prevalence in the colonic mucosa of patients with IBD receiving immunosuppressive therapy. These viruses undergo latency periods which can complicate detection on biopsy.
The prevalence of EBV and CMV co-infection has not been widely studied, however in certain immunocompromised patients it has been documented to cause a hemorrhagic colitis presenting similarly to IBD. As this patient had an underlying diagnosis of UC, differentiating between a flare up and a superimposed viral colitis required tissue diagnosis.
Despite having a co-infection of both CMV and EBV the management of both pathologies with antivirals is the standard of care. Further investigations into the prevalence and symptomatology of EBV and CMV in patients with IBD will be required so that these viral colitis IBD-mimickers may be differentiated from native IBD with prompt initiation of anti-virals.
Figure: Figure 1. (A) Biopsy demonstrates colonic mucosa with prominent lymphoplasmacytic infiltrates and ulcer (H &E stain; 40x magnification). (B) Scattered stromal/endothelial cells with CMV viral cytopathic effect can be seen on H &E stain ("*"; 400x magnification). (C) Confirmatory CMV immunohistochemical stain reveals scattered positive cells (200x magnification). (D) In situ hybridization stain for EBV encoded RNA reveals scattered EBV positive cells (200x magnification).
Tanmay Gaglani indicated no relevant financial relationships.
Samantha Chung indicated no relevant financial relationships.
Rongying Li indicated no relevant financial relationships.
Joshua Balwaa indicated no relevant financial relationships.
Zhenjian Cai indicated no relevant financial relationships.
Scott Larson indicated no relevant financial relationships.
Tanmay Gaglani, MD, Samantha Chung, MD, Rongying Li, MD, Joshua Balwaa, MD, PhD, Zhenjian Cai, MD, PhD, Scott Larson, MD, PhD. P2707 - Human Cytomegalovirus and Epstein-Barr Virus Co-Infection-Induced Colitis Superimposed Upon Ulcerative Colitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.