P2255 - Use of Adalimumab During a Crohn’s Flare Up in the Setting of Active Cytomegalovirus Colitis

Keshavi Mahesh, MD¹, Howard Lewkowitz, MD^2
1Broward Health North, Deerfield Beach, FL; ²Broward Health Imperial Point, Fort Lauderdale, FL

Introduction: Crohn’s disease is a chronic inflammatory bowel disease that affects the digestive tract, causing inflammation, swelling, and ulcers. TNF-a drugs like adalimumab are the primary therapy for moderate to severe Crohn’s disease. The prevalence of cytomegalovirus (CMV) infection in acute severe colitis is between 21 and 34%. The utilization of adalimumab in individuals with active CMV colitis and Crohn’s disease remains uncertain. Some studies suggest adalimumab’s potential effectiveness in treating active CMV colitis in Crohn’s disease, while others express concerns about the potential for worsening of CMV infection. This unique case presents a challenging dilemma of managing a patient with Crohn’s Disease and active CMV colitis.

Case Description/Methods: A 39 -year-old male with HIV and Crohn’s disease presents to the hospital with severe rectal pain and bloody diarrhea. CT abdomen/pelvis revealed perirectal inflammation indicating proctitis. He was admitted for an acute Crohn’s exacerbation and was initiated on IV steroids. Lab results showed leukopenia (WBC: 1.22x10^3uL) and low CD4 count (115 cells/mcL) He endorsed compliance with HIV HAART. He received the starting dose of monoclonal antibody therapy, adalimumab. Proctoscopy revealed severe colitis with deep ulceration and fistula formation. Rectal biopsy showed viral inclusions which confirmed CMV infection. He was started on ganciclovir and adalimumab was discontinued in the setting of active CMV infection along with perianal abscesses and an infected fistula. A week later, he was readmitted for similar symptoms and urgently underwent a diverting colostomy. Ganciclovir was switched to foscarnet due to pancytopenia. CMV viral load was negative after five weeks, and the patient resumed adalimumab treatment.

Discussion: Our case highlights adalimumab’s significant impact in active CMV colitis and Crohn’s disease. Managing such cases involves a delicate balance between treating the inflammatory bowel disease and concerns about CMV complications such as disseminated disease. Upon literature review, there is a paucity of published studies investigating the effects of using immunosuppressive therapy in the setting of active CMV colitis. Our patient’s case contributes to the growing body of evidence and emphasizes the importance of individualized treatment strategies in this unique patient population. Further research and studies in this area is warranted to guide clinical decision making to optimize patient care.



Disclosures:


Keshavi Mahesh, MD¹, Howard Lewkowitz, MD². P2255 - Use of Adalimumab During a Crohn’s Flare Up in the Setting of Active Cytomegalovirus Colitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.