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Case PresentationCase Presentation
• 34 y/o male 34 y/o male
• 5 years Crohn’s disease of ileum and Rt. 5 years Crohn’s disease of ileum and Rt. colon colon
• 10 days – Fever, chills10 days – Fever, chills
Watery diarrhea Watery diarrhea
RLQ abdominal pain RLQ abdominal pain
MedicalMedical HistoryHistory
• Last exacerbation 6m agoLast exacerbation 6m ago
• No surgical historyNo surgical history
• Treatment: Azathioprine 150 mgTreatment: Azathioprine 150 mg
Physical ExaminationPhysical Examination
Fever –38.6, HR-90Fever –38.6, HR-90
Tenderness – RLQ , WithoutTenderness – RLQ , Without
hepatosplenomegaly or ascitishepatosplenomegaly or ascitis
PR- normal PR- normal
No lymphadenpathyNo lymphadenpathy
Heart & lungs- normalHeart & lungs- normal
Laboratory DataLaboratory Data• Hb-Hb-11.511.5, MCV-81,WBC- 3400, Neu- 62%, MCV-81,WBC- 3400, Neu- 62%PLT-197PLT-197
• ALK.P, T Bill- normal, ALT-ALK.P, T Bill- normal, ALT-7171, GGT- , GGT- 110110, , LDH-LDH-746746
• Total Protein - 63 ,ALB - Total Protein - 63 ,ALB - 2929
• Folic acid, B12-normalFolic acid, B12-normal • Blood, urine , fecal culture , CDT -negativeBlood, urine , fecal culture , CDT -negative
ManagementManagement
Treatment 7 days with PO metronidazole Treatment 7 days with PO metronidazole and IV hydrocortisone – without and IV hydrocortisone – without improvementimprovement
• CMV IgG – negativeCMV IgG – negative
• CMV IgM – CMV IgM – positivepositive
• CMV antigenemia – negativeCMV antigenemia – negative
NEXT STEP?NEXT STEP?
CMV COLITISCMV COLITIS AZATHIOPRINEAZATHIOPRINEHYDROCORTISONEHYDROCORTISONE
STARTSTART
CMV IgMCMV IgM??
• 63 patient –Active IBD63 patient –Active IBD
• Evaluated for CMV :Evaluated for CMV :
IgM CMVIgM CMV
PCR – Colonic biopsyPCR – Colonic biopsy
H&E – Inclusion bodyH&E – Inclusion body
Kishore et al. J med microbiol 2004;53
Kishore et al. J med microbiol 2004;53
ILEOCECAL VALVEILEOCECAL VALVE
H&E STAININGH&E STAINING
?
Diagnosis IHC vs H&EDiagnosis IHC vs H&E
Kambham et al. Am J Surg pathol 2004; 28:3
Diagnosis IHC vs H&EDiagnosis IHC vs H&E
Kambham et al. Am J Surg pathol 2004; 28:3
CMV-IHC STAINIGCMV-IHC STAINIG
CMV COLITISCMV COLITIS
• Defective cell-mediated immunity: Defective cell-mediated immunity: • AIDS, organ transplant recipients, AIDS, organ transplant recipients,
immunosuppressionimmunosuppression
• Old age, cancer, CRF, alcoholismOld age, cancer, CRF, alcoholism
• Immunocompetent hosts : Immunocompetent hosts :
Mucosal damageMucosal damage
EPIDEMIOLOGY IN IBDEPIDEMIOLOGY IN IBD
• More common in UCMore common in UC - Prevalence: 4.6% in UC, - Prevalence: 4.6% in UC, 0.80.8% in Crohn’s % in Crohn’s
diseasedisease - 12% of patients with intestinal CMV - 12% of patients with intestinal CMV
infectioninfection Kaufman et al. Dis Colon Rectum 1999; 42: 24Kaufman et al. Dis Colon Rectum 1999; 42: 24
• Usually reactivation of latent virusUsually reactivation of latent virus
PREDISPOSING FACTORSPREDISPOSING FACTORS
• Duration of IBDDuration of IBD• Active inflammationActive inflammation• TreatmentTreatment - - Steroids with other immunosuppressionSteroids with other immunosuppression
Often in a patient who had long been Often in a patient who had long been stablestable
Kishore et al. J med microbiol 2004;53
CLINICAL CHARACTERISTICSCLINICAL CHARACTERISTICS
• Exacerbation of the underlying IBDExacerbation of the underlying IBD• Mononucleosis-like syndromeMononucleosis-like syndrome• Steroid -refractory colitisSteroid -refractory colitis• Additional GI manifestations – oral Additional GI manifestations – oral
lesions, odynopagialesions, odynopagia
Papadakis et al. Am J Gastroenetrolgy 2001; 96:7Kambham et al. Am J Surg pathol 2004; 28:3
DIAGNOSISDIAGNOSIS
• SerologySerology• CMV antigenemiaCMV antigenemia• PCR for CMV PCR for CMV • Endoscopic appearanceEndoscopic appearance - Erosions, ulcerations, mucosal hemorrhage- Erosions, ulcerations, mucosal hemorrhage
• Mucosal biopsy Mucosal biopsy -- Large cells with intranuclear and intracytoplasmic inclusionsLarge cells with intranuclear and intracytoplasmic inclusions
- Immunostaining- Immunostaining - Submucosal vasculitis or microvascular thrombosis- Submucosal vasculitis or microvascular thrombosis
TREATMENT
• Gancyclovir Gancyclovir • 5 mg/kg bid5 mg/kg bid• 6 weeks of intravenous treatment6 weeks of intravenous treatment
• Marked improvement usually noted within a weekMarked improvement usually noted within a week
TREATMENTTREATMENT
STOP!• Steroids (rapid tapering)• Cyclosporin• Azathioprine• 6-MP
IMMUNOSUPPRESSION IMMUNOSUPPRESSION THERAPY RENEWALTHERAPY RENEWAL??