Introduction: Reactivation of latent cytomegalovirus (CMV) is seen in immunocompromised patients. The combined effect of colonic inflammation from ulcerative colitis (UC), and chronic immunosuppression from long-term immunomodulating agents, is theorized to lead to CMV colitis. A superimposed infection on a pre-existing colitis flare further weakens the body’s ability to mount an immune response, complicating the treatment course and consequently resulting in a prolonged recovery period.
Case Description/Methods: A 56-year-old male with a known history of UC on adalimumab presents with intractable, non-bloody watery diarrhea, and recurrent subjective fevers over the past week after returning from a cruise to Puerto Rico. He denies nausea, vomiting, and abdominal pain. No family members were sick. He reported compliance with adalimumab for the past two years with well-controlled symptoms and no infections. His current symptoms are not consistent with prior UC flares. His last colonoscopy one year ago was consistent with stable findings of known UC.
Initial workup was significant for a fever of 102.3F, WBC 4.7E9/L bandemia of 19% without a leukocytosis, CRP of 14.3 mg/dL, and CT abdomen/pelvis with inflammatory changes from the rectum to the distal transverse colon. Symptoms persisted despite a 10-day course of piperacillin-tazobactam. A flexible sigmoidoscopy revealed proctosigmoiditis and scattered viral inclusion bodies, suspicious for CMV infection. CMV DNA PCR of 619 IU/mL and titers of IgM 161 U/mL and IgG 0.62 U/mL confirmed acute infection. The patient was started on IV ganciclovir, but continued to have recurrent daily fevers and persistent diarrhea.
By this time, an exhaustive infectious workup was negative, including blood cultures, clostridium difficile, Escherichia coli, cryptosporidium, norovirus, rotavirus, hepatitis panel, Epstein-Barr virus, legionella, malaria, Q fever, rocky mountain spotted fever, chikungunya, dengue, HIV, syphilis. The patient reluctantly agreed to start high-dose IV steroids and subsequently had symptomatic improvement. He was eventually discharged on home oral valganciclovir and oral high-dose steroids.
Discussion: Concomitant diagnoses may require concomitant, though seemingly contradictory, treatments. Steroids are generally avoided in infectious management, however our patient required high dose steroids in addition to antivirals to counteract an ongoing UC flare. This multimodal treatment regimen optimized our patient's response to simultaneous colitis etiologies.
Disclosures:
Samah Syed indicated no relevant financial relationships.
Samah Syed, DO. P2247 - A Therapeutic Conundrum: Ulcerative Colitis Flare With Concomitant CMV Colitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.
