A female patient, consulted our hospital due to deterioration of her UC under Infliximab-therapy.
The disease started during her second pregnancy 2 years prior to admission. Initially, 5-ASA worked well. Six month later she received corticoids and azathiorpine. The latter was stopped after 2 month due to leucopenia. Infliximab was administered for three month, then clinical symptoms worsened. A biopsy was taken and this biopsy revealed necrotising colitis most likely due to a virus infection. PCR from blood and biopsy for the detection of CMV was negative. Here my question: Which are potential differential diagnosis concerning the virus and what ways of identifying the virus would you suggest?
Dear Christian,
since you have a biopsy (or at least left a paraffin block for former histological diagnosis) I - as a Electron Microscopist - would like to point you to the posibility of selecting a representative area of your histology spec, i.e. selection from representative H&E-slide/section, punching out (say with a 4 or 6mm punch biopsy instrument) the area of interest, "reembedding" that punch specimen [ means: total deparaffinization - including osmication by special technique - reembedding in resin - semithin sectioning - staining - selecting representative area for ultrathin sections - ultrathin sections - observation in TEM ("Correlative LH-LM-TEM")].
Might be not easy for you and the outcome (or perhaps positive localization of virus particles) depending on seriosity and precision of TEM-observation (nevertheless the possibility that virus particles cannot be localized due to virtually non-presence/absence of virusparticles must be expected). But for sure using such a method would be worth a try, especially if you have left more histological biopsy specimens.
I have done such "re-embeddings" quite often and the older as well as more recent literature on outcome of such
Dear Christian
I would suggest that you also consider the possibility of primary failure to infliximab( that is, a non responder patient) and in this case maybe another biological drug such as vedolizumab should work better, and also the possibility of a Clostridium difficile infection. Clostridium infection is more prevalent in IBD patientes, even if they didn't receive antibiotics.
Best regards
Wilson
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