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Alotaibi Y, AlLehibi A, Almtawa A, Alotaibi N, Alghamdi A, Alrajhi S, AlQutub A, AlEid A, Alamr A, Ibrahim BA, Alahmari M, Alhamidi H, Ahmad S, Alshammari F, Almotawa F, Altannir Y, Alghamdi A. Prevalence and Risk Factors of Cytomegalovirus Colitis in Inflammatory Bowel Disease Patients in Riyadh, Saudi Arabia: A Tertiary Center Experience. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2023; 11:305-313. [PMID: 37970458 PMCID: PMC10634466 DOI: 10.4103/sjmms.sjmms_175_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/14/2023] [Accepted: 08/27/2023] [Indexed: 11/17/2023]
Abstract
Background Patients with inflammatory bowel disease (IBD) are at a higher risk of cytomegalovirus (CMV) colitis because of their immunocompromised status. There are no studies from Saudi Arabia regarding the prevalence of CMV colitis in patients with IBD. Objective To determine the prevalence, characteristics, and risk factors of CMV colitis in patients with IBD in Riyadh, Saudi Arabia. Materials and Methods This retrospective study included patients with a confirmed diagnosis of IBD (aged 14-75 years) who were followed up at King Fahad Medical City, a referral care center in Riyadh, between January 2016 and December 2021; patients with indeterminate colitis or incomplete medical records were excluded. Results A total of 341 patients with IBD were included, of which 236 (72.2%) had Crohn's disease (CD) and 105 (27.8%) had ulcerative colitis (UC). Qualitative CMV PCR was done for 192 patients (60 UC and 132 CD patients), of which 14 patients were positive for CMV colitis (7.3%), and all positive CMV colitis cases were among UC patients (23.3%). However, the hematoxylin and eosin (H and E) stain and immunohistochemistry were negative for all patients. Most patients with CMV colitis were on steroids (71.4%), had at least one flare-up (64.3%), and were on biologic treatment (71.4%). Significant predictors of CMV colitis were hemoglobin (OR: 0.7; 95% CI: 0.51-0.96), albumin (OR: 0.88; 95% CI: 0.78-0.98), and C-reactive protein (OR: 1.03; 95% CI: 1.01-1.06) levels. Conclusion This study found that the prevalence of CMV colitis was 7.3% among patients with IBD, and no case was diagnosed in patients with CD. In addition, as all cases diagnosed using qualitative CMV PCR were negative on H and E stain and immunohistochemistry, there is need for large-scale studies to improve the diagnosis of CMV colitis.
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Affiliation(s)
- Yazeed Alotaibi
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abed AlLehibi
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdullah Almtawa
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Nawaf Alotaibi
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Adel Alghamdi
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Saad Alrajhi
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Adel AlQutub
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ahmad AlEid
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrhman Alamr
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Bashaar Al Ibrahim
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed Alahmari
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hussam Alhamidi
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Shameem Ahmad
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Fouad Alshammari
- Department of Internal Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Fahad Almotawa
- Department of Internal Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
- Department of Medicine, University of Bisha, Bisha, Saudi Arabia
| | | | - Ahmed Alghamdi
- Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia
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Goyal G, Zinger T, Warfield D, Cao W. The Trends of Immunohistochemistry for Tissue-Invasive Cytomegalovirus in Gastrointestinal Mucosal Biopsies: A Large Single Academic Center Study. Arch Pathol Lab Med 2021; 146:360-365. [PMID: 34133720 DOI: 10.5858/arpa.2020-0425-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Cytomegalovirus (CMV) immunohistochemistry (IHC) is the most widely used method to diagnose CMV infection/reactivation in tissues in a pathology laboratory. OBJECTIVE.— To improve the efficiency of CMV IHC testing by evaluating immunopositive staining trends of tissue-invasive CMV in the gastrointestinal system. DESIGN.— A total of 1479 individual orders for CMV IHC on gastrointestinal biopsy specimens from 2016 to 2018 were included. The analysis was performed to identify the significant factors contributory to CMV-positive test results. RESULTS.— The overall positivity rate of CMV IHC in our institution is 4.73% (70 of 1479). The positivity rate from physician-requested and pathologist-initiated tests was significantly different (7.54% versus 3.83%, P = .004). Cases with severe inflammation showed a higher positive CMV rate than those with mild inflammation (5.37% versus 2.60%, P = .04). Cytomegalovirus positivity in biopsies from posttransplant patients, inflammatory bowel disease, human immunodeficiency virus (HIV)/common variable immunodeficiency (CVID), cancer, and others was 19.69%, 3.84%, 23.33%, 9.00%, and 2.84%, respectively. The positivity rate among posttransplant, HIV/CVID, or cancer patients was significantly higher than in other populations. Cases tested with multiple tissue blocks generated a higher positivity rate than those with a single block (7.77% versus 3.23%, P < .001). Testing 3 to 4 blocks per case almost tripled the positive CMV detection rate (9.04%). Interestingly, using 5 or more blocks did not further ameliorate the positive CMV detection rate. CONCLUSIONS.— The data revealed that physician request, immunosuppression, multiple blocks, and severe inflammation were strongly related to positive CMV IHC detection rate. These findings might provide value in helping pathologists manage CMV IHC testing more efficiently.
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Affiliation(s)
- Geetika Goyal
- From the Department of Pathology, New York University Langone Health, New York (Goyal, Zinger, Warfield, Cao).,The Department of Pathology, Saint Barnabas Medical Center, Robert Wood Johnson Barnabas Health, Livingston, New Jersey (Goyal)
| | - Tatyana Zinger
- From the Department of Pathology, New York University Langone Health, New York (Goyal, Zinger, Warfield, Cao)
| | - Dana Warfield
- From the Department of Pathology, New York University Langone Health, New York (Goyal, Zinger, Warfield, Cao)
| | - Wenqing Cao
- From the Department of Pathology, New York University Langone Health, New York (Goyal, Zinger, Warfield, Cao)
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Jung KH, Kim J, Lee HS, Choi J, Jang SJ, Jung J, Kim MJ, Chong YP, Lee SO, Choi SH, Kim YS, Woo JH, Park SH, Yang DH, Ye BD, Yang SK, Kim SH. Clinical Implications of the CMV-Specific T-Cell Response and Local or Systemic CMV Viral Replication in Patients With Moderate to Severe Ulcerative Colitis. Open Forum Infect Dis 2019; 6:ofz526. [PMID: 31893211 PMCID: PMC6934884 DOI: 10.1093/ofid/ofz526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/10/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The precise role of cytomegalovirus (CMV) in ulcerative colitis (UC) remains disputed. We evaluated the association of CMV-specific host immune responses and systemic or local viral replication with responses to systemic steroids in patients with moderate to severe UC. METHODS Patients who were hospitalized for moderate to severe UC between April 2015 and June 2016 were enrolled. At baseline, all enrolled patients underwent CMV-specific enzyme-linked immunospot assays, quantitative polymerase chain reaction (qPCR) analysis of blood and colonic tissue for CMV viral load, histopathological testing for CMV in colonic tissue by hematoxylin and eosin staining, and immunohistochemical (IHC) analysis. Clinical responses to steroid therapy based on the Oxford index were assessed on day 3. RESULTS Of the 80 patients evaluated, 28 (35.0%) had poor responses to steroid therapy on day 3 of intensive treatment. The presence of inclusion bodies (32.1%) and high-grade (≥3) positivity on IHC (50.0%), as well as colonic (mean 1440.4 copies/mg) and blood (mean, 3692.6 copies/mL) CMV viral load, were higher in steroid-refractory UC patients than the control group (13.5%, 1.9%, mean 429.2 copies/mg, and mean 231.2 copies/mL, respectively; P = .046, .009, .017, and .002, respectively). However, CMV-specific T-cell responses were not associated with steroid-refractory UC. Multivariate analysis revealed that a higher Mayo score (odds ratio [OR], 2.00; P = .002) and higher blood CMV viral load via qPCR analysis (OR, 3.58; P = .044) were independent risk factors for steroid-refractory UC. CONCLUSIONS In patients with moderate to severe UC, higher Mayo score and blood CMV expression determined by qPCR are independently associated with steroid refractoriness. CLINICALTRIALSGOV REGISTRATION NUMBER NCT02439372.
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Affiliation(s)
- Kyung Hwa Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jihun Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho-Su Lee
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jene Choi
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Se Jin Jang
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Correspondence: S.-H. Kim, MD, PhD, Department of Infectious Diseases, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea ()
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Hissong E, Chen Z, Yantiss RK. Cytomegalovirus reactivation in inflammatory bowel disease: an uncommon occurrence related to corticosteroid dependence. Mod Pathol 2019; 32:1210-1216. [PMID: 30952971 DOI: 10.1038/s41379-019-0258-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 02/07/2023]
Abstract
Cytomegalovirus promotes mucosal injury in patients with inflammatory bowel disease, historically affecting 10-25% of ulcerative colitis patients with refractory disease. Viral reactivation is likely related to long-term corticosteroid therapy, which is no longer central to maintenance of patients with inflammatory bowel disease. We hypothesize that viral detection rates have decreased in the modern era, reflecting widespread use of immunomodulatory agents to control inflammation. We performed this study to evaluate the relationships between medical regimens and cytomegalovirus detection rates among patients with inflammatory bowel disease. We searched our database for all patients with established inflammatory bowel disease and severe flares diagnosed from 2002 to 2017. Patients maintained with corticosteroid therapy were considered to be corticosteroid-dependent and those treated with other agents were classified as corticosteroid-independent, provided they had not received corticosteroids within 6 months of colonoscopy. Biopsy samples were reviewed for viral inclusions and subjected to cytomegalovirus immunohistochemistry, and rates of viral detection were compared between groups. There were 135 corticosteroid-dependent patients; most had ulcerative colitis flares occurring during the 2002-2009 period. Patients with ulcerative colitis and Crohn disease were equally represented in the corticosteroid-independent group (n = 133) and most were evaluated for disease flares during the 2010-2017 interval. Cytomegalovirus was detected in 13 (8%) cases; 9 (69%) were diagnosed from 2002 to 2009 and all were obtained from corticosteroid-dependent patients (p = < 0.001). We conclude that rates of cytomegalovirus-related enterocolitis are declining among inflammatory bowel disease patients, reflecting a shift away from corticosteroid-based maintenance therapy in favor of more effective agents that do not promote viral reactivation.
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Affiliation(s)
- Erika Hissong
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Zhengming Chen
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Rhonda K Yantiss
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
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Kredel LI, Mundt P, van Riesen L, Jöhrens K, Hofmann J, Loddenkemper C, Siegmund B, Preiß JC. Accuracy of diagnostic tests and a new algorithm for diagnosing cytomegalovirus colitis in inflammatory bowel diseases: a diagnostic study. Int J Colorectal Dis 2019; 34:229-237. [PMID: 30276706 DOI: 10.1007/s00384-018-3170-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The optimal method for detecting CMV colitis in patients with inflammatory bowel disease (IBD) has not been established. We wanted to investigate which diagnostic test would be most accurate when defining CMV colitis rather by the further clinical course than by using another diagnostic modality. METHODS All consecutive patients with moderately or severely active IBD who had been tested for CMV by PCR, histology, or antigenemia assay at the two campuses CBF and CCM of the Charité - Universitätsmedizin Berlin between September 2006 and September 2009 were included in this retrospective study. During that time, in patients with a positive CMV test, immunosuppressive treatment of any kind was immediately reduced and antiviral treatment was started. This allowed identifying patients who responded to antiviral treatment and those who only responded to later escalation of immunosuppressive therapy. RESULTS One hundred and nine patients were identified, out of whom nine were considered to have clinically relevant CMV colitis. Sensitivity and specificity were 1 and 0.94 for CMV PCR and 0.5 and 1 for pp65 antigen immunofluorescence assay from peripheral blood, 0.67 and 0.98 for immunohistochemistry, and 0.17 and 0.98 for hematoxylin-eosin staining. When using absence of leukocytosis, splenomegaly, and steroid refractory disease as clinical parameters to test for CMV colitis, blood CMV PCR and immunohistochemistry were able to exclude CMV colitis in negative patients with a 75% likelihood of positive patients to have clinically relevant CMV colitis. CONCLUSIONS Blood-based CMV PCR together with simple clinical parameters can exclude clinically relevant CMV colitis at a high specificity.
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Affiliation(s)
- Lea I Kredel
- Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Pamela Mundt
- Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203, Berlin, Germany
- Praxis Jessen + Kollegen, Akademische Lehrpraxis der Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Linda van Riesen
- Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203, Berlin, Germany
- Klinik für Innere Medizin - Schwerpunkt Gastroenterologie, DRK Kliniken Westend, Berlin, Germany
| | - Korinna Jöhrens
- Institut für Pathologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jörg Hofmann
- Institut für Virologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Britta Siegmund
- Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Jan C Preiß
- Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 30, 12203, Berlin, Germany.
- Klinik für Innere Medizin - Gastroenterologie, Diabetologie und Hepatologie, Vivantes Klinikum Neukölln, Berlin, Germany.
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Mavropoulou E, Ternes K, Mechie NC, Bremer SCB, Kunsch S, Ellenrieder V, Neesse A, Amanzada A. Cytomegalovirus colitis in inflammatory bowel disease and after haematopoietic stem cell transplantation: diagnostic accuracy, predictors, risk factors and disease outcome. BMJ Open Gastroenterol 2019; 6:e000258. [PMID: 30899538 PMCID: PMC6398871 DOI: 10.1136/bmjgast-2018-000258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/27/2018] [Accepted: 12/28/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Concurrent cytomegalovirus (CMV) colitis in inflammatory bowel disease (IBD) and after haematopoietic stem cell transplantation (HSCT) is an important clinical entity associated with high rates of morbidity and mortality. METHODS A retrospective study of 47 patients with IBD and 61 HSCT patients was performed regarding the evaluation of diagnostic accuracy of applied methods, predictors, risk factors for CMV disease manifestation, the proportion of patients with antiviral treatment and disease outcome. RESULTS The sensitivity of quantitative PCR (qPCR) with a cut-off value of >250 copies/mg for CMV colitis in patients with IBD and HSCT patients was 79% and 92%, respectively. Predictors for CMV colitis in the IBD cohort were anaemia and the presence of endoscopic ulcers. Glucocorticoids, calcineurin inhibitors and >2 concurrent lines of treatment with immunosuppressive drugs could be identified as risk factors for CMV colitis in the IBD cohort with an OR of 7.1 (95% CI 1.7 to 29.9), 21.3 (95% CI 2.4 to 188.7) and 13.4 (95% CI 3.2 to 56.1), respectively. Predictors and risk factors for CMV gastroenteritis in the HSCT cohort was the presence of endoscopic ulcers (OR 18.6, 95% CI 3.3 to 103.7) and >2 concurrent lines of treatment with immunosuppressive drugs. Antiviral therapy was administered in 70% of patients with IBD and 77% of HSCT patients with CMV disease. 71% of antiviral-treated patients with IBD showed an improvement of their disease activity and 14% underwent colectomy. The mortality rate of HSCT patients was 21% irrespective of their CMV status. CONCLUSIONS In addition to the implementation of histological methods, qPCR may be performed in patients with suspected high-risk IBD and HSCT patients for CMV colitis. Independent validations of these results in further prospective studies are needed.
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Affiliation(s)
- Eirini Mavropoulou
- Department of Gastroenterology and Gastrointestinal Oncology, Universitatsklinikum Gottingen, Gottingen, Germany
| | - Kristin Ternes
- Department of Gastroenterology and Gastrointestinal Oncology, Universitatsklinikum Gottingen, Gottingen, Germany
| | - Nicolae-Catalin Mechie
- Department of Gastroenterology and Gastrointestinal Oncology, Universitatsklinikum Gottingen, Gottingen, Germany
| | | | - Steffen Kunsch
- Department of Gastroenterology and Gastrointestinal Oncology, Universitatsklinikum Gottingen, Gottingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, Universitatsklinikum Gottingen, Gottingen, Germany
| | - Albrecht Neesse
- Department of Gastroenterology and Gastrointestinal Oncology, Universitatsklinikum Gottingen, Gottingen, Germany
| | - Ahmad Amanzada
- Department of Gastroenterology and Gastrointestinal Oncology, Universitatsklinikum Gottingen, Gottingen, Germany
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Siegmund B. Cytomegalovirus infection associated with inflammatory bowel disease. Lancet Gastroenterol Hepatol 2018; 2:369-376. [PMID: 28397701 DOI: 10.1016/s2468-1253(16)30159-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/11/2016] [Accepted: 10/13/2016] [Indexed: 12/18/2022]
Abstract
Refractory colitis in patients with inflammatory bowel disease is a complicated clinical disorder that might, in some patients, even necessitate surgery. Hence the diagnosis of additional complications is of utmost importance. Colitis mediated by cytomegalovirus is one such complication. The high seroprevalence and latent nature of cytomegalovirus, with the possibility of viral replication without mediating disease, poses a real challenge for the diagnosis of cytomegalovirus-mediated colitis. The challenge in daily clinical practice is to distinguish cytomegalovirus replication from cytomegalovirus-mediated colitis in patients with inflammatory bowel disease who have refractory colitis. This Review discusses the scientific literature and provides a diagnostic and therapeutic algorithm for clinical practice.
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Affiliation(s)
- Britta Siegmund
- Medizinische Klinik für Gastroenterologie, Infektiologie, Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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Evidence-based consensus on opportunistic infections in inflammatory bowel disease (republication). Intest Res 2018; 16:178-193. [PMID: 29743831 PMCID: PMC5934591 DOI: 10.5217/ir.2018.16.2.178] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/08/2018] [Accepted: 04/16/2018] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) patients are a high-risk population for opportunistic infections. The IBD group of the Chinese Society of Gastroenterology of the Chinese Medical Association organized an expert group to discuss and develop this consensus opinion. This consensus opinion referenced clinical study results from China and other countries to provide guidance for clinical practices. Eight major topics, including cytomegalovirus infection, Epstein-Barr virus infection, viral hepatitis, bacterial infection, Mycobacterium tuberculosis infection, fungal infection, parasitic infection, and vaccines were introduced in this article.
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Evidence-based consensus on opportunistic infections in inflammatory bowel disease. J Dig Dis 2018; 19:54-65. [PMID: 29330905 DOI: 10.1111/1751-2980.12578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2018] [Indexed: 01/30/2023]
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10
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Paul M, Gupta E, Jain P, Rastogi A, Bhatia V. Diagnostic utility of quantitative cytomegalovirus DNA polymerase chain reaction in intestinal biopsies from patients with inflammatory bowel disease. J Lab Physicians 2018; 10:38-43. [PMID: 29403203 PMCID: PMC5784291 DOI: 10.4103/jlp.jlp_94_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Diagnostic utility of cytomegalovirus (CMV) DNA quantitative polymerase chain reaction (qPCR) in inflammatory bowel disease (IBD) has not been established. We aimed to compare diagnostic utility of qPCR for CMV in biopsy specimens with blood, serology, and histopathology. MATERIALS AND METHODS A total of 132 patients were included (92 ulcerative colitis [UC], 9 Crohn's disease, and 31 unclassified IBD). Comparison between CMV IgM, CMV DNA qPCR in biopsy, in blood and histopathology was done. Positive result in any of the test was considered as CMV infection. Various risk factors for CMV association with IBD were analyzed. RESULTS Confirmed CMV infection was seen in 41 (31.1%) patients. Diagnostic sensitivity of different assays was: DNA in biopsy seen in 37 (90.2%), DNA in blood in 19 (46.3%), CMV IgM in 15 (36.5%), and histopathology in 8 (19.5%). Thirty-two UC cases were further followed up for a median time of 14.0 (R: 3-31) months. They were grouped as group I - biopsy and blood DNA both positive (14, 43.7%), Group II - biopsy positive and blood negative (17, 53.1%), and Group III - biopsy negative but blood positive (1, 3.1%). CMV DNA viral load in Group I was significantly higher (mean: 4.2 ± 1.0 log10 copies/mg) than Group II (mean: 3.2 ± 0.6 copies/mg) and Group III (viral load: 2.69 log10 copies/ml), P < 0.001. Steroid refractoriness was seen more in Group I cases (n = 9) P < 0.001. A cutoff of ≥2.5 log10 copies/mg of DNA in tissue was predictive for steroid refractoriness (AUROC = 0.84). CONCLUSIONS Quantitation of CMV DNA in intestinal biopsy is a useful diagnostic tool and can predict response to steroid treatment in patients with UC.
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Affiliation(s)
- Mousumi Paul
- Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ekta Gupta
- Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India
- Address for correspondence: Dr. Ekta Gupta, Department of Clinical Virology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi - 110 070, India. E-mail:
| | - Priyanka Jain
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Umar S, Clarke K, Bilimoria F, Bilal M, Singh S, Silverman J. Diagnostic yield from colon biopsies in patients with inflammatory bowel disease and suspected cytomegalovirus infection: is it worth it? Ann Gastroenterol 2017; 30:429-432. [PMID: 28655979 PMCID: PMC5479995 DOI: 10.20524/aog.2017.0153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 04/21/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) are often immunosuppressed and are at risk for reactivation of latent cytomegalovirus (CMV) infection. We examined the diagnostic yield from colon biopsies in IBD patients with suspected CMV infection. METHODS Patients above 18 years of age who underwent testing for CMV on colon biopsies between January 1st, 2012, and December 31st, 2015, were identified from a pathology data base. A positive CMV result was included only if testing included both hematoxylin/eosin staining and immunohistochemistry from two or more biopsy samples. RESULTS One hundred twenty-five patients met the inclusion criteria. Of these, 99 had a diagnosis of IBD: 30 with Crohn's disease, 63 with ulcerative colitis, and 6 with indeterminate colitis. As regards treatment, 21.2% of the patients had biologic therapy alone, 13.1% received immunomodulators, and 11.1% were treated with combined biologic and immunomodulator therapy within 3 months of the colon biopsy. In addition, 32.3% of the patients were on steroids. Of the 99 IBD patients, only 1 had biopsy-proven CMV colitis. CONCLUSION The yield from colon biopsies with hematoxylin/eosin staining and immunohistochemistry to test for CMV in IBD flare is very low. Further multicenter studies with large numbers of patients are needed to compare all testing modalities in the same cohort of patients. This may help identify which subgroup of IBD patients are likely to benefit from specific modalities of CMV testing, with potential cost-saving implications.
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Affiliation(s)
- Shifa Umar
- Department of Internal Medicine (Shifa Umar)
| | - Kofi Clarke
- Division of Gastroenterology, Hepatology and Nutrition (Kofi Clarke, Shailendra Singh)
| | - Farshaad Bilimoria
- Department of Pathology (Farshaad Bilimoria, Jan Silverman), Allegheny Health Network, Pittsburgh, PA
| | - Mohammad Bilal
- Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX (Mohammad Bilal), USA
| | - Shailendra Singh
- Division of Gastroenterology, Hepatology and Nutrition (Kofi Clarke, Shailendra Singh)
| | - Jan Silverman
- Department of Pathology (Farshaad Bilimoria, Jan Silverman), Allegheny Health Network, Pittsburgh, PA
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Park SC, Jeen YM, Jeen YT. Approach to cytomegalovirus infections in patients with ulcerative colitis. Korean J Intern Med 2017; 32:383-392. [PMID: 28490715 PMCID: PMC5432807 DOI: 10.3904/kjim.2017.087] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/06/2017] [Indexed: 12/16/2022] Open
Abstract
Cytomegalovirus (CMV) reactivation is common in patients with severe ulcerative colitis (UC), and may ref lect exacerbation of mucosal inf lammation and/or administration of immunosuppressants. The question of whether CMV is an active pathogen or 'an innocent bystander' in the exacerbation of UC remains controversial. Patients with UC exacerbated by reactivated CMV experience worse prognoses than those without CMV reactivation and antiviral therapy significantly reduces the need for colectomy in patients with severe UC and high-grade CMV infection, indicating that CMV plays a role in UC prognosis. Therefore, the CMV status of patients on immunosuppressants, particularly those with steroid-refractory or -dependent UC, should be tested. When CMV is detected, be performed based on should adequate treatment the extent of the viral load and the presence of certain clinical features including a large ulcer. Anti-tumor necrosis factor agents may be useful for treating CMV colitis complicating UC.
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Affiliation(s)
- Sung Chul Park
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Yoon Mi Jeen
- Department of Pathology, Soon Chun Hyang University Seoul Hospital, Seoul, Korea
- Correspondence to Yoon Mi Jeen, M.D. Department of Pathology, Soon Chun Hyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea Tel: +82-2-709-9435 Fax: +82-2-709-9441 E-mail:
| | - Yoon Tae Jeen
- Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
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14
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Weng MT, Tung CC, Lee YS, Leong YL, Shieh MJ, Shun CT, Wang CY, Wong JM, Wei SC. Cytomegalovirus colitis in hospitalized inflammatory bowel disease patients in Taiwan: a referral center study. BMC Gastroenterol 2017; 17:28. [PMID: 28193173 PMCID: PMC5307794 DOI: 10.1186/s12876-017-0586-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 02/09/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Colitis is exacerbated in patients with concurrent cytomegalovirus (CMV) infection and inflammatory bowel disease (IBD). We assessed the prevalence and clinical features of CMV colitis in hospitalized IBD patients. METHODS A retrospective study reviewed the data from January 1, 1998 through December 31, 2013 compiled at the National Taiwan University Hospital. The CMV colitis patients' demographic data, clinical information, treatment regimens, pathologic findings, and outcome were analyzed. RESULTS A total of 673 IBD patients were hospitalized during the study period. There were 312 patients diagnosed with Crohn's disease (CD) and 361 with ulcerative colitis (UC). CMV colitis was diagnosed as having positive inclusion bodies in colonic tissue. Six of the 312 CD patients (1.9%) and five of the 361 UC patients (1.4%) were diagnosed with CMV colitis. Compared to CD patients without CMV colitis, patients with CMV colitis were more often older (p < 0.005). Higher steroid usage was noted in the CMV positive group compared to age and gender matched CMV negative IBD patients (81.8% vs. 51.5%). Eight patients received ganciclovir treatment. Three patients who did not receive antiviral treatment had colitis flare-ups after the index admission. CONCLUSIONS The prevalence of CMV colitis in hospitalized IBD inpatients was 1.6% in Taiwan. Two associated factors for CMV colitis in hospitalized IBD patients were that they were elderly in CD and were on higher doses of steroids. Routine histopathology studies and/or PCR for refractory colitis patients are suggested to diagnose CMV colitis. Once the diagnosis is made, antiviral treatment is recommended to decrease the colitis relapse rate.
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Affiliation(s)
- Meng-Tzu Weng
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7 Chung-Shan South Road, Taipei City, Taiwan
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Chemical Engineering & Materials Science, Yuan-Ze University, Taoyuan, Taiwan
| | - Chien-Chih Tung
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7 Chung-Shan South Road, Taipei City, Taiwan
| | - Yi-Shuan Lee
- Department of Pathology and Forensic Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Yew-Loong Leong
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7 Chung-Shan South Road, Taipei City, Taiwan
- Department of Internal Medicine, West Garden Hospital, Taipei City, Taiwan
| | - Ming-Jium Shieh
- Department of Oncology, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Chia-Tung Shun
- Department of Pathology and Forensic Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7 Chung-Shan South Road, Taipei City, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7 Chung-Shan South Road, Taipei City, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, No. 7 Chung-Shan South Road, Taipei City, Taiwan.
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15
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Juric-Sekhar G, Upton MP, Swanson PE, Westerhoff M. Cytomegalovirus (CMV) in gastrointestinal mucosal biopsies: should a pathologist perform CMV immunohistochemistry if the clinician requests it? Hum Pathol 2017; 60:11-15. [PMID: 27666768 DOI: 10.1016/j.humpath.2016.09.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/31/2016] [Accepted: 09/02/2016] [Indexed: 01/01/2023]
Abstract
Cytomegalovirus (CMV) causes clinically significant gastrointestinal (GI) injury. CMV inclusions can be identified on routine hematoxylin and eosin (H&E) stain, but immunohistochemistry (IHC) is also available for identifying CMV in tissue. The advent of accountable care organization models of care bring into question whether it is cost-effective for immunohistochemistry to be performed upfront at the request of clinicians and whether the quality of viral detection is compromised when the diagnosis of CMV is predicated on histologic review. In this study, a retrospective review of GI biopsies with CMV evaluations was performed. There were 449 cases with clinical requests to rule out CMV and 238 CMV analyses initiated by the pathologist without a clinical request. Among the cases that included a clinician's request, 37 had CMV detected. Immunostaining was performed on 26 cases, while a diagnosis based on readily identifiable viral inclusions on H&E-stained slides was made in 11. Among pathologist-initiated work-ups, 15 were CMV+, 3 of which had inclusions identified by H&E only. Among 38 CMV cases for which IHC had been performed, 27 had overt viral inclusions obvious on H&E. Seventy-two cases revealed uninflamed GI mucosa, and although a clinical concern about CMV infection was present, a CMV IHC work-up was not initially performed; all were negative for CMV by IHC and H&E. Clinical suspicion for CMV has a high yield for CMV detection, but "upfront" testing is likely unnecessary. Careful histopathologic review by a pathologist remains critical in the efficient and cost-effective detection of CMV.
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Affiliation(s)
| | - Melissa P Upton
- Department of Pathology, University of Washington, Seattle, WA, 98195 USA
| | - Paul E Swanson
- Department of Pathology, University of Washington, Seattle, WA, 98195 USA
| | - Maria Westerhoff
- Department of Pathology, University of Washington, Seattle, WA, 98195 USA.
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Beswick L, Ye B, van Langenberg DR. Toward an Algorithm for the Diagnosis and Management of CMV in Patients with Colitis. Inflamm Bowel Dis 2016; 22:2966-2976. [PMID: 27763950 DOI: 10.1097/mib.0000000000000958] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Concurrent cytomegalovirus (CMV) in inflammatory bowel disease-related colitis is an important yet complex clinical scenario associated with high rates of colectomy and other morbidity. This review aimed to examine the literature to produce a comprehensive diagnostic and treatment algorithm for the management of CMV in patients with colitis. METHODS A systematic literature review was conducted via PubMed/Medline databases until August 31, 2015, using multiple keywords in English language and where original data only presented. RESULTS This review discusses the concept of CMV reactivation which frequently occurs in inflammatory bowel disease-related colitis, most commonly in those presenting with steroid-refractory colitis. In this context, although signifying a poorer prognosis, in most cases, the virus is nonpathogenic and thus antiviral treatment is unhelpful. However, when reactivation gives rise to true CMV disease (colitis) as best discriminated by histology with immunohistochemistry (and the density of such) in colonic biopsy tissue, the patient does benefit from antivirals. CONCLUSION Diagnostic-based patient selection and treatment is integral to optimal outcomes in CMV, and therefore we propose an algorithm based on these concepts that now requires prospective evaluation.
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Affiliation(s)
- Lauren Beswick
- *Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia; and †Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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17
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Hirayama Y, Ando T, Hirooka Y, Watanabe O, Miyahara R, Nakamura M, Yamamura T, Goto H. Characteristic endoscopic findings and risk factors for cytomegalovirus-associated colitis in patients with active ulcerative colitis. World J Gastrointest Endosc 2016; 8:301-309. [PMID: 27014426 PMCID: PMC4804188 DOI: 10.4253/wjge.v8.i6.301] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 09/11/2015] [Accepted: 01/19/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To identify characteristic endoscopic findings and risk factors for cytomegalovirus (CMV)-associated colitis in patients with active ulcerative colitis (UC).
METHODS: A total of 149 UC patients admitted to the Department of Gastroenterology, Nagoya University Hospital, from January 2004 to December 2013 with exacerbation of UC symptoms were enrolled in this retrospective study. All medical records, including colonoscopy results, were reviewed. CMV infection was determined by the presence of CMV antigen, CMV inclusion bodies in biopsy specimens, or positive specific immunohistochemical staining for CMV. Multivariate analysis was used to identify independent risk factors for CMV colitis.
RESULTS: Multivariate analysis indicated independent associations with the extent of disease (pancolitis) and use of > 400 mg corticosteroids for the previous 4 wk. In contrast, no association was seen with sex, age at UC diagnosis, immunomodulator use, or infliximab use. Punched-out ulceration was also significantly associated with CMV infection in patients with active UC (odds ratio = 12.672, 95%CI: 4.210-38.143).
CONCLUSION: Identification of a total corticosteroid dose > 400 mg for 4 wk, extensive colitis and a specific endoscopic finding of punched-out ulcer might facilitate the more rapid diagnosis and timely initiation of antiviral therapy for CMV-associated colitis in patients with active UC.
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18
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Yassin MA, Nashwan AJ, Soliman AT, Yousif A, Moustafa A, AlBattah A, Mohamed SF, Mudawi DS, Elkourashy S, Asaari DR, Gutierrez HLG, Almusharaf M, Hussein RM, Moustafa AH, Derhoubi HE, Boukhris S, Kohla S, AlDewik N. Cytomegalovirus-induced Hemorrhagic Colitis in a Patient with Chronic Myeloid Leukemia (Chronic Phase) on Dasatinib as an Upfront Therapy. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2015; 8:77-81. [PMID: 26379451 PMCID: PMC4554353 DOI: 10.4137/ccrep.s25327] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 05/10/2015] [Accepted: 05/15/2015] [Indexed: 02/03/2023]
Abstract
Dasatinib is a kinase inhibitor indicated for the treatment of newly diagnosed adults with Philadelphia chromosome-positive (Ph+) chronic myeloid leukemia (CML) in chronic phase and accelerated (myeloid or lymphoid blast) phase, and CML with resistance or intolerance to prior therapy including imatinib and in adults with Ph+ acute lymphoblastic leukemia1 The most common adverse reactions (≥15%) in patients with newly diagnosed chronic-phase (CP) CML include myelosuppression, fluid retention, and diarrhea, whereas in patients with resistance or intolerance to prior imatinib therapy, side effects include myelosuppression, fluid retention, diarrhea, headache, dyspnea, skin rash, fatigue, nausea, and hemorrhage. We report a 39-year-old Ethiopian female patient who received dasatinib as upfront therapy for the treatment of CP-CML who experienced chronic diarrhea for two months, which progressed to hemorrhagic colitis due to cytomegalovirus (CMV) infection of the colon. To our knowledge, this is the first case of CMV colitis in a patient receiving dasatinib as upfront therapy.
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Affiliation(s)
- Mohamed A Yassin
- National Center for Cancer Care and Research, Department of Hematology and BMT, Hamad Medical Corporation, Doha, Qatar
| | - Abdulqadir J Nashwan
- National Center for Cancer Care and Research, Department of Nursing, Hamad Medical Corporation, Doha, Qatar
| | | | - Anil Yousif
- National Center for Cancer Care and Research, Department of Hematology and BMT, Hamad Medical Corporation, Doha, Qatar
| | - Afra Moustafa
- National Center for Cancer Care and Research, Department of Hematology and BMT, Hamad Medical Corporation, Doha, Qatar
| | - Afaf AlBattah
- National Center for Cancer Care and Research, Department of Hematology and BMT, Hamad Medical Corporation, Doha, Qatar
| | - Shehab F Mohamed
- National Center for Cancer Care and Research, Department of Hematology and BMT, Hamad Medical Corporation, Doha, Qatar
| | - Deena S Mudawi
- National Center for Cancer Care and Research, Department of Hematology and BMT, Hamad Medical Corporation, Doha, Qatar
| | - Sarah Elkourashy
- National Center for Cancer Care and Research, Department of Hematology and BMT, Hamad Medical Corporation, Doha, Qatar
| | - Deena-Raiza Asaari
- National Center for Cancer Care and Research, Department of Nursing, Hamad Medical Corporation, Doha, Qatar
| | - Hope-Love G Gutierrez
- National Center for Cancer Care and Research, Department of Nursing, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Almusharaf
- National Center for Cancer Care and Research, Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Radwa M Hussein
- National Center for Cancer Care and Research, Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | | | - Hatim El Derhoubi
- National Center for Cancer Care and Research, Department of Hematology and BMT, Hamad Medical Corporation, Doha, Qatar. ; Department of Radiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Sarra Boukhris
- National Center for Cancer Care and Research, Department of Hematology and BMT, Hamad Medical Corporation, Doha, Qatar
| | - Samah Kohla
- Department of Pathology, AlAzhar University, Doha, Qatar
| | - Nader AlDewik
- Qatar Medical Genetic Center, Hamad Medical Corporation, Doha, Qatar
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Sager K, Alam S, Bond A, Chinnappan L, Probert CS. Review article: cytomegalovirus and inflammatory bowel disease. Aliment Pharmacol Ther 2015; 41:725-33. [PMID: 25684400 DOI: 10.1111/apt.13124] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 09/04/2014] [Accepted: 01/27/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The association between ulcerative colitis and cytomegalovirus (CMV) has been recognised for over 50 years; and the role of CMV in ulcerative colitis in general, and steroid resistance in particular, remains a topic of ongoing controversy. The outcome for patients with CMV reactivation appears worse than that for patients without reactivation, but it is not entirely clear whether CMV is a contributor or a bystander and if treatment with anti-virals alters the course of inflammatory bowel disease (IBD). AIM To review the role of CMV associated with IBD, including epidemiology, clinical features, diagnosis and management strategies. METHODS By reviewing literature available on CMV associated with IBD in adult patients. A PubMed literature search was performed using the following terms individually or in combination: CMV colitis, cytomegalovirus colitis, IBD and CMV, CMV treatment. RESULTS Cytomegalovirus reactivation is common in patients with severe colitis, with a reported prevalence of 4.5-16.6%, and as high as 25% in patients requiring colectomy for severe colitis. The outcome for this group of patients appears worse than that for patients without reactivation; however, reported remission rates following treatment with anti-viral therapy are as high as 71-86%. CONCLUSIONS Evidence, although not conclusive, supports testing for CMV colonic disease in cases of moderate to severe colitis, by processing biopsies for haematoxylin and eosin staining with immunohistochemistry and/or, CMV DNA real-time polymerase chain reaction; and if present treating with ganciclovir.
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Affiliation(s)
- K Sager
- Department of Gastroenterology, Royal Liverpool University Teaching Hospital, Liverpool, UK
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20
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Bassotti G, Antonelli E. Is it possible to identify patients with inflammatory bowel disease who are at risk for cytomegalovirus infection? Clin Gastroenterol Hepatol 2015; 13:138-9. [PMID: 25066836 DOI: 10.1016/j.cgh.2014.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 07/18/2014] [Accepted: 07/18/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Gabrio Bassotti
- Gastroenterology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
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21
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Olaisen M, Rydning A, Martinsen TC, Nordrum IS, Mjønes P, Fossmark R. Cytomegalovirus infection and postoperative complications in patients with ulcerative colitis undergoing colectomy. Scand J Gastroenterol 2014; 49:845-52. [PMID: 24947587 DOI: 10.3109/00365521.2014.929172] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ulcerative colitis (UC) can be complicated by reactivation of cytomegalovirus (CMV). CMV reactivation may change the course of UC and may require antiviral treatment. Some risk factors of CMV reactivation have previously been identified, whereas the association between CMV reactivation and postoperative complications has not been examined systematically. METHODS Patients with UC operated with colectomy due to active UC were studied (n = 77). Patient and disease characteristics, as well as postoperative complications were recorded and CMV was detected by immunohistochemical examination of multiple sections from the colectomy specimen. RESULTS CMV was found in nine (11.7%) colectomy specimens. CMV-positive patients received significantly higher doses of corticosteroids at colectomy than CMV-negative patients (61.1 ± 23 vs 32.5 ± 32 mg/day, p = 0.01). CMV-positive patients were also older, had a higher risk of severe complications, higher American Society of Anesthesiologists (ASA) score, longer preoperative stay, and a higher rate of acute surgery. Complications occurred in 30 (39%) patients after surgery, 8(10.4%) of whom were serious. Two CMV-positive patients (2.6%) died in-hospital after the colectomy. High ASA score was associated with the occurrence of serious complications. CONCLUSION A relatively small proportion of patients with UC operated by colectomy were CMV positive. CMV positivity was associated with old age, high dose of corticosteroids at operation, high ASA score, acute surgery, and severe postoperative complications. Patients with such characteristics may be at risk of CMV infection and may require special management.
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Affiliation(s)
- Maya Olaisen
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU) , Trondheim , Norway
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22
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Monterrubio Villar J, Pérez Holgado MV, Jiménez Delgado JD, Almaraz Velarde R, Veiga González MD. [Severe colitis due to cytomegalovirus in a patient with idiopathic CD4 lymphocytopenia]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:464-6. [PMID: 24447887 DOI: 10.1016/j.gastrohep.2013.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 11/30/2013] [Accepted: 12/04/2013] [Indexed: 12/20/2022]
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Garrido E, Carrera E, Manzano R, Lopez-Sanroman A. Clinical significance of cytomegalovirus infection in patients with inflammatory bowel disease. World J Gastroenterol 2013; 19:17-25. [PMID: 23326158 PMCID: PMC3545225 DOI: 10.3748/wjg.v19.i1.17] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/03/2012] [Accepted: 08/14/2012] [Indexed: 02/06/2023] Open
Abstract
Cytomegalovirus (CMV) infection is common in humans. The virus then enters a “latency phase” and can reactivate to different stimuli such as immunosuppression. The clinical significance of CMV infection in inflammatory bowel disease is different in Crohn’s disease (CD) and ulcerative colitis (UC). CMV does not interfere in the clinical course of CD. However, CMV reactivation is frequent in severe or steroid-resistant UC. It is not known whether the virus exacerbates the disease or simply appears as a bystander of a severe disease. Different methods are used to diagnose CMV colitis. Diagnosis is classically based on histopathological identification of viral-infected cells or CMV antigens in biopsied tissues using haematoxylin-eosin or immunohistochemistry, other tests on blood or tissue samples are currently being investigated. Polymerase chain reaction performed in colonic mucosa has a high sensitivity and a positive result could be associated with a worse prognosis disease; further studies are needed to determine the most appropriate strategy with positive CMV-DNA in colonic mucosa. Specific endoscopic features have not been described in active UC and CMV infection. CMV colitis is usually treated with ganciclovir for several weeks, there are different opinions about whether or not to stop immunosuppressive therapy. Other antiviral drugs may be used. Multicenter controlled studies would needed to determine which subgroup of UC patients would benefit from early antiviral treatment.
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Ji Y, Li RP, Wang ML. Progress in understanding the relationship between inflammatory bowel disease and human cytomegalovirus infection. Shijie Huaren Xiaohua Zazhi 2012; 20:2070-2074. [DOI: 10.11569/wcjd.v20.i22.2070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Human cytomegalovirus (HCMV) is a ubiquitous DNA virus that can cause severe disease in immunosuppressive or immunocompromised patients. Recent studies have found that CMV might play a role in the pathogenesis and progression of inflammatory bowel disease (IBD). This paper gives a review of the epidemiology, clinical diagnosis, and pathogenesis of HCMV infection in patients with IBD.
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26
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Abstract
Ulcerative colitis (UC) patients are believed to have an increased risk for the colonic reactivation of cytomegalovirus (CMV) infection due to both inherent and iatrogenic factors. Numerous studies and case reports have described CMV infection as complicating the disease course of ulcerative colitis patients; the existing evidence suggests an association between the presence of CMV infection and increased colectomy and mortality rates in UC patients. Whether CMV is nonpathogenic with a tropism towards areas of dysplasia and inflammation in the colon of UC or plays an active role in pathogenesis is still debated. In this paper, we examine the existing evidence for the diagnosis and management of CMV infection in UC patients.
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27
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Cytomegalovirus infection in patients with active inflammatory bowel disease. Dig Dis Sci 2010; 55:1059-65. [PMID: 20112061 DOI: 10.1007/s10620-010-1126-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Accepted: 01/11/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND The reported prevalence of cytomegalovirus (CMV) infection with active inflammatory bowel disease (IBD) is highly variable, and whether CMV negatively impacts the clinical course is controversial. AIMS The aim of this study was to determine the prevalence of CMV in patients with active ulcerative colitis (UC) or Crohn's disease (CD) and compare the course of disease in patients with and without CMV. METHODS Consecutive patients with acute exacerbations of active IBD colitis had immunohistochemistry staining for CMV antigen performed on archived specimens. Clinical features were retrospectively reviewed. RESULTS Twelve (10%) of 122 UC patients had CMV, and 0/20 patients with CD had CMV. Of 12 UC patients with CMV infection, seven were not taking steroids or immunosuppressives at their index flare. UC patients with CMV were more likely to have leukocytosis (OR = 5.3, 95% CI 1.5-18.2), require hospitalization (OR = 4.9, 95% CI 1.2-19.0), and be hospitalized > or =7 days (OR = 5.0, 95% CI 1.6-21.3) compared to patients without CMV. Of 12 UC patients with CMV, ten (83%) were treated for their index flare with steroids or 6-mercaptopurine. Only one patient (8%) was treated for CMV infection which occurred 14 months after index endoscopy. Over the 6 months after the index flare, UC patients with CMV had a higher frequency of IBD-related hospitalizations compared to patients without CMV (50 vs. 24%, P = 0.021), but none required surgery or died. CONCLUSIONS The prevalence of CMV with active UC was 10%. Although CMV infection may be a marker of disease severity, our results suggest it does not cause severe morbidity or mortality in a general population of patients with a UC flare.
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Suzuki H, Kato J, Kuriyama M, Hiraoka S, Kuwaki K, Yamamoto K. Specific endoscopic features of ulcerative colitis complicated by cytomegalovirus infection. World J Gastroenterol 2010; 16:1245-51. [PMID: 20222169 PMCID: PMC2839178 DOI: 10.3748/wjg.v16.i10.1245] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify specific colonoscopic findings in patients with ulcerative colitis (UC) complicated by cytomegalovirus (CMV) infection.
METHODS: Among UC patients who were hospitalized due to exacerbation of symptoms, colonoscopic findings were compared between 15 CMV-positive patients and 58 CMV-negative patients. CMV infection was determined by blood test for CMV antigenemia. Five aspects of mucosal changes were analyzed (loss of vascular pattern, erythema, mucosal edema, easy bleeding, and mucinous exudates) as well as five aspects of ulcerative change (wide mucosal defect, punched-out ulceration, longitudinal ulceration, irregular ulceration, and cobblestone-like appearance). Sensitivity, specificity, positive predictive value, and negative predictive value of each finding for CMV positivity were determined.
RESULTS: The sensitivity of irregular ulceration for positive CMV was 100%. The specificity of wide mucosal defect was 95%. Punched-out ulceration and longitudinal ulceration exhibited relatively high sensitivity and specificity (more than 70% for each).
CONCLUSION: Specific colonoscopic findings in patients with UC complicated by CMV infection were identified. These findings may facilitate the early diagnosis of CMV infection in UC patients.
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29
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Maher MM, Nassar MI. Acute cytomegalovirus infection is a risk factor in refractory and complicated inflammatory bowel disease. Dig Dis Sci 2009; 54:2456-62. [PMID: 19093204 DOI: 10.1007/s10620-008-0639-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Accepted: 11/12/2008] [Indexed: 12/12/2022]
Abstract
The role of cytomegalovirus (CMV) infection in patients with inflammatory bowel disease (IBD) is controversial. Although CMV has been specifically associated with refractory disease, the strength and nature of this association have been a subject of debate. The aim of this study was to evaluate the prevalence and outcome of acute cytomegalovirus infection in patients with severe refractory and complicated inflammatory bowel disease. Seventy-two patients with active IBD (both ulcerative colitis [UC] and Crohn's diseases [CD]) were included in this study. Thorough history taking and physical examination of all patients was made with special emphasis on symptoms and signs of CMV disease. Colonoscopic assessment was made for the extent and activity of IBD and collection of specimen. Prevalence of CMV infection was estimated by serology; anti-CMV IgM and IgG antibodies, and pathologic studies of colonic biopsies used conventional haematoxylin and eosin (H & E) and immunohistochemistry (IHC) with monoclonal antibodies. Complete blood count and liver function tests were done for all patients. Among 72 patients with active inflammatory bowel disease, 23 (31.9%) were resistant to intravenous steroids. CMV was detected in eight (six with UC and two with CD) of the 23 (34.8%) steroid-resistant patients and in only one (3.2%) patient in the remaining 31 patients under steroid treatment and was not detected in 18 IBD patients not using steroids. Among nine CMV-positive IBD patients, six (66.6%) were female and six had fever; cervical lymphadenopathy was found in five patients and splenomegaly in two, compared to no patients in the CMV-negative group (P = 0.01 and 0.03, respectively). Leucopenia and thrombocytopenia were predominantly seen in the CMV-positive versus CMV-negative patients (2.1+/-0.3 vs. 5.9+/-3.4 and 98+/-34 vs. 165+/-101, respectively). Pancolitis was found in five of nine CMV-positive IBD patients whereas in only two patients out of 63 in the CMV-negative group (P = 0.005). Acute CMV infection in patients with IBD is not rare and is often underestimated. CMV infection in patients with refractory or complicated IBD should be ruled out before aggressive immunosuppressive therapy. High clinical index of suspicion for the association of CMV infection with IBD should be directed towards female IBD patients presenting with fever, lymphadenopathy, splenomegaly, leucopenia, and mild hepatitis. CMV IHC is significantly more sensitive than routine H & E stain and should be considered as part of the routine evaluation of IBD patients with severe exacerbation or steroid-refractory disease before proceeding with other medical or surgical therapy that may not be necessary once the CMV is treated.
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Affiliation(s)
- Maha M Maher
- Department of Internal Medicine, Mansoura University, Mansoura, Egypt,
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30
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Baroco AL, Oldfield EC. Gastrointestinal cytomegalovirus disease in the immunocompromised patient. Curr Gastroenterol Rep 2008; 10:409-16. [PMID: 18627655 DOI: 10.1007/s11894-008-0077-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cytomegalovirus (CMV) has emerged as a significant opportunistic pathogen in the era of immunosuppression. CMV was a common cause of gastrointestinal disease in AIDS patients, but the introduction of highly active antiretroviral therapy has led to a dramatic decline in AIDS-related disease. Among patients with solid organ transplants, CMV has become an increasingly important cause of gastrointestinal disease as more routine use of early CMV prophylaxis has increased delayed-onset disease, which is often tissue invasive at presentation. The role of CMV in inflammatory bowel disease is controversial; treatment may be indicated in selected cases of steroid-refractory disease with evidence of CMV. Diagnosis of gastrointestinal CMV disease generally requires endoscopic biopsy with histologic confirmation. CMV culture of biopsy material may be falsely positive because of contamination from latently infected cells. The standard induction treatment of gastrointestinal CMV disease uses intravenous ganciclovir, though the use of oral valganciclovir is increasing, especially for long-term maintenance or suppression therapy.
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Affiliation(s)
- Allison L Baroco
- Eastern Virginia Medical School, Department of Internal Medicine, Division of Infectious Diseases, 825 Fairfax Avenue, Suite 410, Norfolk, VA 23507, USA.
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31
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de Avila RE, Batista TS, Xavier MAP, Nogueira AMMF, Lambertucci JR. Schistosomiasis mansoni and severe gastrointestinal cytomegalovirus disease in a patient with acquired immunodeficiency syndrome. Rev Soc Bras Med Trop 2007; 39:379-82. [PMID: 17119755 DOI: 10.1590/s0037-86822006000400012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2005] [Accepted: 07/12/2006] [Indexed: 11/21/2022] Open
Abstract
The behavior of the Schistosoma mansoni infection in patients with AIDS has not been explored. The case of a young woman with schistosomiasis mansoni, AIDS, and cytomegalovirus disease is reported. The authors suggest that the helminth was not a bystander in this case, or rather, by interfering with the host's immune response, it set the stage for the development and/or aggravation of the viral infection.
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Affiliation(s)
- Renata Eliane de Avila
- Serviço de Doenças Infecciosas e Parasitárias, Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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32
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Abstract
When patients with inflammatory bowel disease (IBD) are admitted to the hospital with a flare of acute severe colitis, the possibility of a concurrent cytomegalovirus (CMV) infection causing or worsening the colitis is often considered. IBD patients are usually immunosuppressed, and therefore presumably at increased risk for active CMV infection and disease. Multiple techniques are used to diagnose CMV infection, including endoscopy, histology, serology, viral culture, CMV antigen testing, and CMV DNA testing. Immunohistochemistry (IHC) performed on colon biopsy specimens with monoclonal antibodies directed against CMV immediate early antigen is considered by most to be the current gold standard for diagnosis. The prevalence of CMV infection in acute severe colitis appears to be 21-34%, and the prevalence of CMV infection in the steroid refractory subgroup of these patients is 33-36%. After antiviral therapy, colitis remission rates in IBD patients with CMV infection range from 67% to 100%, though CMV histological infection or the presence of circulating virus alone is not always associated with steroid resistance, and may not require antiviral therapy.
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Affiliation(s)
- Ahmed Kandiel
- Center for Inflammatory Bowel Disease, Department of Gastroenterology/Hepatology, Cleveland Clinic, Cleveland, Ohio 44195, USA
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33
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Oku T, Maeda M, Waga E, Wada Y, Nagamachi Y, Fujita M, Suzuki Y, Nagashima K, Niitsu Y. Cytomegalovirus cholangitis and pancreatitis in an immunocompetent patient. J Gastroenterol 2005; 40:987-92. [PMID: 16261436 DOI: 10.1007/s00535-005-1683-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Accepted: 06/20/2005] [Indexed: 02/04/2023]
Abstract
Cholangitis and pancreatitis associated with cytomegalovirus (CMV) infection in an immunocompetent patient is reported. Endoscopic retrograde cholangiography performed on a 55-year-old man for evaluation of the cause of jaundice and liver dysfunction revealed a distal focal irregular narrowing of the common bile duct. Microscopic findings of the resected specimen showed chronic cholangitis and CMV pancreatitis. Immunohistochemistry disclosed that epithelial cells in the inflamed bile duct were positive for CMV antigen, which was compatible with CMV cholangitis. Inflammation of the biliary tract or pancreas by CMV has been commonly reported as a complication in immunocompromised patients. Our report appears to be a rare case, but suggests that CMV cholangitis or pancreatitis should be considered in the differential diagnoses of common bile duct stenosis or pancreatitis even in immunocompetent individuals.
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Affiliation(s)
- Takatomi Oku
- Department of Gastroenterology, Shinnittetsu Muroran General Hospital, 1-45 Chiribetsu-cho, Muroran, 050-0076, and Department of Internal Medicine, Sapporo Medical University, School of Medicine, Japan
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Kishore J, Ghoshal U, Ghoshal UC, Krishnani N, Kumar S, Singh M, Ayyagari A. Infection with cytomegalovirus in patients with inflammatory bowel disease: prevalence, clinical significance and outcome. J Med Microbiol 2004; 53:1155-1160. [PMID: 15496396 DOI: 10.1099/jmm.0.45629-0] [Citation(s) in RCA: 155] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Despite frequent use of immunosuppressive drugs in patients with inflammatory bowel disease (IBD) and reports of cytomegalovirus (CMV) infection following post-transplant immunosuppression, data on the frequency and clinical significance of CMV in patients with IBD are scant. Sixty-three patients with IBD (61 ulcerative colitis and two Crohn's disease) were evaluated for CMV using serology (IgM antibody, μ-capture ELISA), PCR for CMV DNA in colonic biopsy and histological assessment of haematoxylin and eosin-stained colonic biopsy. Positive result in any test was considered as CMV infection. Various parameters associated with CMV infection were analysed using univariate and multivariate analysis. Ten of 63 (15.8 %) patients (age 36.0 ± 11.2 years, 31 female) were infected with CMV (DNA alone in four, IgM antibody alone in two and both in four, inclusion body in one). Patients with CMV infection were more often female (8/10 vs 23/53,P< 0.05), had pancolitis (10/10 vs 33/53,P< 0.05), histological activity (9/10 vs 17/53,P< 0.005) and used azathioprine (5/10 vs 7/53,P= 0.04; Fisher exact test for all). On multivariate analysis, female gender, pancolitis and histological activity were the independent factors associated with infection. Patients with CMV infection more often required surgical treatment for IBD (4/10 vs 4/53,P= 0.01) and had fatal outcome (3/10 vs 0/53,P= 0.003). CMV infection in patients with IBD may be common and is associated with poor outcome. PCR of rectal biopsy was the most sensitive method of detection followed by IgM antibody for diagnosis.
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Affiliation(s)
- Janak Kishore
- Departments of Microbiology1, Gastroenterology2 and Pathology3, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Ujjala Ghoshal
- Departments of Microbiology1, Gastroenterology2 and Pathology3, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Uday C Ghoshal
- Departments of Microbiology1, Gastroenterology2 and Pathology3, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Narendra Krishnani
- Departments of Microbiology1, Gastroenterology2 and Pathology3, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Sanjay Kumar
- Departments of Microbiology1, Gastroenterology2 and Pathology3, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Manisha Singh
- Departments of Microbiology1, Gastroenterology2 and Pathology3, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Archana Ayyagari
- Departments of Microbiology1, Gastroenterology2 and Pathology3, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
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35
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Sugisaki K, Maekawa S, Mori K, Ichii O, Kanda K, Tai M, Suzuki T, Ochiai H, Ejiri Y, Takahashi M, Hakozaki H. Self-limited colitis during the course of rubella and cytomegalovirus infection in an immunocompetent adult. Intern Med 2004; 43:404-9. [PMID: 15206554 DOI: 10.2169/internalmedicine.43.404] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a case of self-limited colitis in cytomegalovirus (CMV) infection in an immunocompetent adult. A 22-year-old man developed a high fever and diarrhea. Laboratory data revealed an increased number of lymphocytes and liver damage. Enzyme immunoassays for anti-virus antibodies revealed that the patient was recently infected with CMV and rubella. Colonoscopy revealed severe erosive and edematous mucosa that resembled ulcerative colitis (UC). The symptoms, laboratory data and colonoscopic findings improved without any medical treatment. This case indicates that UC-like self-limited colitis can occur in an immunocompetent individual during the course of CMV infection.
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Affiliation(s)
- Kota Sugisaki
- Division of Gastroenterology, Fukushima Rosai Hospital, 3 Numajiri, Tsuzurimachi, Uchigo, Iwaki 973-8403
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Wolf T, Bickel M, Faust D, Fellbaum C, Brodt HR. A case of severe CMV-colitis in an HIV positive patient despite moderate immunodeficiency. ACTA ACUST UNITED AC 2004; 35:904-6. [PMID: 14723380 DOI: 10.1080/00365540310017096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
CMV-colitis is rare in HIV positive patients with CD4 counts higher than 100 microl(-1). We report a patient who was suffering from extensive CMV-colitis despite modest immune defect. The diagnosis was confirmed by repeated biopsies. The patient experienced an unusually long recovery which was only achieved after initiation of HAART.
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Affiliation(s)
- Timo Wolf
- Department of Infectious Diseases, JWG University, Frankfurt, Germany.
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Abstract
It is now more than two decades since the AIDS epidemic began with a cluster of Pneumocystis carinii pneumonia (PCP) in a community of homosexual men. Since then, many other infections have been characterized as opportunistic infections secondary to HIV infection. These include, but are not limited to, infections with Toxoplasma gondii, Cytomegalovirus (CMV), Mycobacterium avium complex (MAC), and Cryptococcus neoformans. Over the last two decades, there have been dramatic improvements in diagnosis, prevention and treatment of all these infections. As a result, in North America and Western Europe the rates of opportunistic infections secondary to AIDS have decreased substantially. We will review these common opportunistic infections below.
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Affiliation(s)
- Rafik Samuel
- Section of Infectious Diseases, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA.
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38
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Abstract
Chronic HIV-associated diarrhea is currently a field in flux. Improved noninvasive diagnostic tests, improved pathogen-specific regimens, and better empiric therapies may change some of the assumptions used to select algorithms for diagnostic evaluation and management. Any shift in the cause of diarrhea from pathogen-associated to idiopathic or a reduction in the overall incidence of diarrhea would have considerable impact. It is unclear how significant the problem of pathogen relapse in previous responders will become. Existing studies reviewed in this article show that the high diagnostic yield of endoscopy when stool tests are negative, coupled with significantly better outcomes when pathogens are identified, support the current practice of routine endoscopic evaluation. There currently are scant data on the economic impact of HIV-associated diarrhea as it relates to pathogen-specific and empiric therapy in the era of protease inhibitors. Such data would be integral to future evaluation of the impact of diagnostic and therapeutic strategies.
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Affiliation(s)
- J Cohen
- Division of Gastroenterology, Department of Medicine, New York University School of Medicine, New York, New York, USA
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39
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Reijasse D, Patey-Mariaud de Serre N, Canioni D, Huerre M, Haddad E, Leborgne M, Blanche S, Brousse N. Cytotoxic T cells in AIDS colonic cryptosporidiosis. J Clin Pathol 2001; 54:298-303. [PMID: 11304847 PMCID: PMC1731408 DOI: 10.1136/jcp.54.4.298] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS It is not known how enteric cryptosporidiosis induces severe intestinal impairment despite minimal invasion by the parasite. The aim of this study was to analyse the histological features and locally implicated immune cells in colonic biopsies of AIDS related cryptosporidiosis. PATIENTS/METHODS Colonic biopsies from patients with AIDS related cryptosporidiosis (n = 10, group I), patients with AIDS but without intestinal infection (n = 9, group II), and human seronegative controls (n = 9, group III) were studied. Using immunohistochemistry the infiltrating mononuclear cells were analysed in both the epithelium and lamina propria for the expression of CD3, CD8, TiA1, granzyme B, and CD68 and for glandular expression of human major histocompatibility complex DR antigen (HLA-DR). RESULTS Severe histological changes, resulting in abundant crypt epithelial apoptosis and inflammatory infiltrate in the lamina propria, were seen in all biopsies from group I. A significant increase of CD8+, TiA1+, and granzyme B+ T cells in the lamina propria and HLA-DR glandular expression was noted in group I compared with groups II and III. However, the number of intraepithelial lymphocytes, lamina propria CD3+ T cells, and macrophages was not significantly increased in cryptosporidiosis specimens compared with controls. CONCLUSION Epithelial apoptosis mediated by granzyme B+ cytotoxic host T cells might play a major role in the development of colonic lesions in AIDS related cryptosporidiosis.
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Affiliation(s)
- D Reijasse
- Department of Pathology and Université René Descartes-Paris V (EA 219), Paris, France
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40
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Klauber E, Briski LE, Khatib R. Cytomegalovirus colitis in the immunocompetent host: an overview. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 1999; 30:559-64. [PMID: 10225382 DOI: 10.1080/00365549850161098] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This paper describes 2 immunocompetent patients with cytomegalovirus colitis and reviews all previously reported cases (n = 13). Affected patients were generally older (69.13+/-15.62 y-old) with probable reactivation (n = 8) or younger (43.86+/-19.73 y-old) with probable primary infection (n = 7). The onset of illness was found to be hospital-associated in 4 (50.0%) reactivation cases and 1 (14.3%) primary case. Presenting manifestations included diarrhoea (86.7%), fever (80.0%), gastrointestinal bleeding (66.7%) and abdominal pain (60.0%). Endoscopy showed erosive colitis with multiple (n = 11; 73.3%) or single ulcers (n = 2, 13.3%); biopsy was diagnostic in 12/13 (92.3%) patients. Complications included massive haemorrhage (13.3%), toxic megacolon (13.3%), perforation (13.3%) and protracted inflammatory bowel disease (20.0%; exclusively in primary-infection). The mortality rate was 26.7%. Antiviral-agents were given in 8 (53.3%) cases; assessment of treatment-efficacy was not possible. In conclusion, cytomegalovirus colitis in the immunocompetent-host is a rare but potentially severe erosive disease with significant morbidity. It may occur during primary infection or reactivation; the diagnosis requires careful histopathological examination and the benefit of antiviral-therapy is unknown.
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Affiliation(s)
- E Klauber
- Department of Medicine, St John Hospital and Medical Center, Detroit, Michigan 48236, USA
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