A young 11 years old girls is newly diagnosed with ulcerative colitis, pancolitis moderate to severe type. The PCR For CMV is positive in colon. Does she need CMV treatment in addition to induction with steroids?
We have already started Induction with steroids with some response og PCR For CMV from colon is positive. Do we need to start antiviral treatment immediately or can we wait and see the Induction response first and if it is refractory colitis can we then start the antiviral treatment
There are reports and trials supporting both. Some report that CMV as long as IG is low has a high likelyhood of resolving by itself. On the other hand the risk of worse clinical course is higher with IS and CMV. Patients more often require surgery. However I would also reffere to histology and immunglobulines. If in doubt and CMV is clearly apperent I would reccomend tretment with Ganciclovir.
Ref:
Cytomegalovirus is frequently reactivated and disappears without antiviral agents in ulcerative colitis patients.
Matsuoka K, Iwao Y, Mori T, Sakuraba A, Yajima T, Hisamatsu T, Okamoto S, Morohoshi Y, Izumiya M, Ichikawa H, Sato T, Inoue N, Ogata H, Hibi T.
Am J Gastroenterol. 2007 Feb;102(2):331-7. Epub 2006 Dec 11.
J Med Microbiol. 2004 Nov;53(Pt 11):1155-60.
Infection with cytomegalovirus in patients with inflammatory bowel disease: prevalence, clinical significance and outcome.
Kishore J1, Ghoshal U, Ghoshal UC, Krishnani N, Kumar S, Singh M, Ayyagari A.
Very frequently, you will find a positive CMV-PCR of the colon in an acitve UC patient.
In our departement (one of the major IBD centers in Germany), we don´t rely on mucosal CMV PCR results since this method is by far to sensitive to distiguish between low CMV transcription due to inflammation and clinical relevant CMV reactivation.
In our daily practice, a clinical significant CMV reactivation is characerized by expression of the CMV-Antigen (Immunhistology) or typical morphological changes in conventional histolooathology (large intranuclear inclusion bodies and smaller cytoplasmic inclusions).
Besides this, we have established a cut-off value for CMV-PCR-levels from peripheral blood(study in 40 CMV-PCR+ patients -data not yet published), which is around 4000 copies. Below this level, we rate the finding as "not clinical significant".
We are waiting for CMV antigen ( immunohistology ) and bloodtest to check CMV srology and CMV CPR .
I agree completely with these answers
As a matter of fact CMV is frequent and never disappears totally and specific treatment is warranted only if the virus is active
I agree to all the above. In immunocompetent patients CMV is an innocent by stander and this probably is the case as your patient is a "naive" UC. I would be interested to see the data by DR Maul. In case UC becomes steroid refractory or non responsive I would go for ganscyclovir therapy. Further you may check ECCO guide lines (2012)
The pt did not respond to per oral steroid therapy . One week after per oral steroid she developed signs of systemic toxicity in the form of fever , tachycardia , anemia , leukocytosis , raised ESR & CRP , abdominal pain . She had already bloody lose stools both on day and in night .
I think if toxic megacolon is ruled out and new unpreped flex sigmoidoscopy plus biopsies is consistent with active disease, switch to IV steroids and if in the next 4 days CRP does not improve think of remicade.
As the patient is not responding well and you would increase the IS, you have the presence of CMV; I would cover the CMV as well. It maybe an innocent bystander, but the threshold from when it converts from a bystander to particpiant would be difficult to identify, the chances for this change with increasing IS. Wait for IHC, if its positive start therapy, if IHC will take long/clinical worsening present/ planned increase in IS => start treatment.
In UC patients CMV PCR can be positive without any clinical relevance. it is important only if {a) IN inclusion bodies are positive on biopsy, (b) there is definite worsening in pre existent UC, (C) CMV antgen is positive. However one should be careful when giving steroids to such patients as there can be flare of "bystander" CMV.
Cite
Arshad Sultan
Vestre Viken Hospital Trust
We started i.v steroid and Cymvane . Pas responded very good . After 3 days had noe fever , CRP , leukocytes normalisert . Stools max 4-5 times/day and very littel blood in stools . PUCAI reudced from 65 to 40 in 4 days . She responded to Cymvane i.v and is clinicla fin . I.v steroides are stopped already but gettiing i.v cymvane .
Thanks for good response and opinions .
Cite
Hassan Vossoughinia
Mashhad University of Medical Sciences
I prefer to start treatment of UC and CMV infection,concomitantly.
Cite
Arshad Sultan
Vestre Viken Hospital Trust
The pt was treated with i.v steroides and i.v cymvane . PO steroides was started after few days .
Histology did not show intracellular inclusion bodies . CMV IgG was positiv but CMV IgM was negative in serum . We stoppes i. v cymavene after histology did not show inclusion bodies .
Pt is clinically fine on p.o prednisolone and 5 ASA .
Thanks for input from all collegues .
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