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Background

We present an unusual case of cytomegalovirus (CMV) colitis found in an immunocompetent pregnant patient with Ulcerative pancolitis. This case illustrates the importance of recognizing CMV as a potential cause for a colitis flare.

Methods

A 32-year-old woman G2P1 at 30 weeks gestational age with Ulcerative pancolitis in clinical remission on mesalamine extended release 1.5 grams/day presented to her obstetrician with 1 week of loose bloody bowel movements up to 7 times per day, lower abdominal cramping and urgency. Her hemoglobin was 10.9 mg/dL, ESR was 41, and CRP was 2.052. Stool culture and Clostridium difficile PCR were negative. She was diagnosed with Ulcerative colitis in 2002. Her disease has been reasonably controlled on oral 5-Aminosalicylate drugs with 5 flares in 11 years requiring oral steroids, the last in 2008. She was started on oral prednisone 40 mg daily. After 3 days with no improvement, she was admitted for intravenous methylprednisolone 40 mg daily. Flexible sigmoidoscopy was performed for tissue biopsy. Tissue biopsies showed active chronic colitis with mild architectural distortion and enlarged cells with intranuclear inclusions, positive by immunohistochemical staining for CMV. Serum CMV DNA PCR was 3,250 IU/mL. Intravenous ganciclovir 5 mg/kg twice per day for 14 days was added to her therapy, and she was transitioned to oral prednisone following excellent response to IV ganciclovir and methylprednisilone. The patient is currently in complete clinical remission after two weeks of treatment with IV ganciclovir, and is tolerating steroid taper.

Results

Inflammatory bowel disease (IBD) is a chronic inflammatory condition with a waxing and waning clinical course. Several studies have reported a similar rate of flare between pregnant and non-pregnant patients, estimated to be between 26% and 34%. Steroid therapy is an essential part of treatment. Some studies have shown steroid-resistant disease in 15% of ulcerative colitis patients and 20% in Crohn’s disease with the prevalence of CMV infection between 21% and 36%. The clinical significance of CMV infection in inflammatory bowel disease has been a matter of debate with some studies suggesting that CMV is a bystander in severe disease, especially in the immunosuppressed, while others correlate flares with CMV disease. There are no large randomized controlled trials discussing the impact of CMV therapy in patients with IBD flares. Further, there is scant data on how to treat CMV colitis in pregnant patients.

Conclusions

Diagnosis of CMV colitis must be considered in patients with severe colitis flare not responding to steroid therapy. This is imperative before initiation of immunosuppressive therapies. Timely diagnosis and treatment of CMV colitis helped attain remission and avoid complications of disease flare in our pregnant patient in third trimester of her pregnancy.

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Copyright © 2013 Crohn's & Colitis Foundation of America, Inc.
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