Cytomegalovirus Infection in Patient with Refractory Ulcerative Colitis: Prevalence, Outcome and Therapeutic Effect of Antiviral Treatment

Abstract

Background & Aim: Cytomegalovirus (CMV) infection has been reported as a cause of refractory ulcerative colitis (UC), but the natural history of CMV infection related to the development and treatment of UC has not been clarified. In some cases, CMV infection is associated with a poor outcome but it is not clear which patients are more likely to be affected and in which stage of the disease. The aim of this study was to evaluate the prevalence, outcome and therapeutic effect of antiviral treatment of CMV infection in a consecutive series of patients with severe steroid refractory UC. Methods: The subjects were a total of 78 patients with severe UC at our Hospital between 1990 and 2006 in the study. Forty-six patients were identified with refractory UC, defined as poor response to high-dose systemic steroids (refractory UC). Patients were evaluated for CMV by using serology (antigenemia), and histopathological assessment of hematoxylin-eosin (HE) and immunohistchemical (CMV IgG antibodies)-stained colonic biopsies. Positive result in any test was considered as CMV infection. We studied refractory UC with CMV for frequency, clinical characteristic, outcome of medical treatment, and therapeutic effect of antiviral treatment (Ganciclovir; GCV). Results: The prevalence of CMV infection in the steroid-refractory UC was 39.1% (18/46). There was no difference in the CMV infection rate between males and females (males, 9/24; 37.5% and females, 9/22; 40.9%). In case of UC with refractory lesion, there is a high possibility that treatment is ineffective (73.0%). In endoscopic finding, longitudinal ulcer (65.9%) and extensive mucosal abrasion (61.0%) were found with high frequency, and there were refractory lesion significantly in depths of the colon. Of 18 refractory UC with CMV detected, 13 (72.2%) were refractory to steroids and other immunosuppressive drugs, and had undergone. Of 13 refractory UC with CMV treated with GCV, 9 (71.5%) temporally obtained remission by first anti-virus medication, otherwise 5 of 9 patients responded by GCV were fared up and was operated on. Only 5 patients went into remission after antiviral treatment (10.8 ± 7.2 month). Conclusions: CMV infection is a frequent cause of severe refractory UC. The findings of this study suggest that it is very important to decide on a patient's medication by relying on exact diagnosis concerning the condition of UC by endoscopy. Further, GCV is useful for treatment of CMV-associated UC after immunosuppressive therapy. UC patients with CMV infection more often required surgical treatment (13/18, 72.2%) and is associated with poor outcome.