Epstein-Barr Virus Mucocutaneous Colonic Ulcer in an Immunocompetent Patient

Abstract

Epstein Barr virus (EBV) positive mucocutaneous ulcers (MCU) were first described in 2010 in immunosuppressed individuals. Lesions have been noted in the oral mucosa, skin, and gastrointestinal tract. Although these lesions are typically benign and will heal with conservative therapy with reversal of immunosuppression, rare reports have described progression to disseminated Hodgkin's lymphoma (HL). We report a case of EBVMCU in an immunocompetent patient during a period of active EBV infectious mononucleosis superimposed on campylobacter colitis. A 47-year-old, previously healthy male presented to the hospital for evaluation for a 1-month history of bloody diarrhea associated with recent development of pharyngitis and flu-like symptoms. Physical exam noted pharyngeal erythema, symmetrical bilateral cervical lymphadenopathy with diffuse abdominal tenderness to palpation. Initial labs noted normal hemoglobin and WBC with a lymphocyte predominance. Transaminases were elevated with an AST 202 U/L, ALT 410 U/L and an alkaline phosphatase of 870 U/L. CT of his abdomen and pelvis revealed circumferential thickening of the rectum with inflammatory stranding, diffuse pelvic, abdominal, and thoracic lymphadenopathy, splenomegaly, and multiple hepatic lesions: collectively concerning for malignancy. Serum AFP, CEA, CA 19-9, and HIV markers were normal. Fecal calprotectin was elevated over 830ug/g. Hepatic MRI noted presence of cysts. Stool cultures were positive for campylobacter. He was started on azithromycin and after several days of therapy, symptoms did not improve. Colonoscopy revealed several clean based ulcers in the rectum and sigmoid-colon (Figure 1) with biopsies positive for EBVMCU (Figure 2). Serum EBV IgM was positive. He was ultimately discharged in stable condition with instructions for close follow-up. To date, 51 cases of EBVMCU have been described in the literature, 5 of which developed within the colon. All reports describe a predisposing factor of immunosuppression by either medication or age-related immunosenescence in patients >60. We report a presumed novel case in which colonic EBVMCU developed in a young immunocompetent patient during active EBV infection superimposed with campylobacter colitis. It is imperative to keep a broad differential and investigate persistent symptoms despite a diagnosis. EBVMCU falls on a spectrum of EBV-associated proliferative disorders, including HL, thus close surveillance is needed to ensure disease resolution.Figure: Colonoscopy acquired images depicting several clean based rectal ulcers.Figure: (Left) H&E stain of rectal ulcer noting colonic mucosa with dense lymphoplasmacyctic infiltrate. (Right) EBV in situ hybridization indicating presence of EBV DNA within the nuclei of infected cells.