S1928 Seeing the Forest for the Trees: Not All Colitis Is IBD

Abstract

Introduction: Gastrointestinal involvement by Epstein-Barr virus (EBV) infection is rare, and almost always occurs in states of immunodeficiency or chronic inflammation. We present a case of EBV colitis in a healthy immunocompetent patient. Case description/methods: A 33-year-old man presented with 3 weeks of bloody diarrhea, fatigue, malaise, and weight loss. On exam, he had tender cervical lymphadenopathy. Labs showed leukocytosis of 19.2 K/UL (64% lymphocytes), hemoglobin of 11.5 g/dL, and elevated CRP of 23.8 mg/L. Liver enzymes were elevated, with ALT of 156 U/L, AST of 125 U/L, and alkaline phosphatase of 220 U/L. Albumin (4 g/dL) and platelets (221 K/UL) were normal. Tests for HIV, viral hepatitis, and stool bacteria, ova, and parasites were negative. Computed tomography showed splenomegaly, enlarged intraabdominal lymph nodes, and diffuse colon wall thickening with hyperemia. Colonoscopy revealed patchy ulcers, friability, and erythema in the colon, with normal intervening mucosa and terminal ileum. He was referred to the Inflammatory Bowel Disease (IBD) service, and initial pathology showed mild active chronic pancolitis. Due to symptom severity, he was started on IV methylprednisolone 20 mg twice daily and rapidly improved in 2 days. Final pathology showed positive EBV-encoded small RNA (EBER) in situ hybridization (50 cells/hpf) without evidence of an underlying lymphoproliferative disorder. Serologies showed acute EBV infection (IgM+, IgG-, PCR viral load 341 IU/mL), and liver biopsy showed EBV hepatitis. Infectious Disease (ID) agreed with supportive therapy. He was discharged on 5 days of prednisone 40 mg daily. On 1-week follow up, he was asymptomatic off steroids. Repeat colonoscopy will be performed in 3 months. Discussion: Acute EBV infection classically presents with lymphadenopathy, splenomegaly, and constitutional symptoms. EBV colitis is exceedingly rare in immunocompetent patients, especially in the absence of lymphoma, with only 3 published case reports. Our case highlights the importance of maintaining a holistic approach to arrive at a unifying diagnosis. EBV in colon biopsies is not always pathologic; serologies are needed to determine active or latent infection. Coordinating with ID is prudent. Management is typically supportive, given the self-limited course; the role of corticosteroids and antivirals remains unclear. Repeat colonoscopy with biopsies to evaluate mucosal healing and to rule out underlying IBD is recommended.Figure 1.: Figure 1A. 4.3 x 3.5 cm mass anterior to a large sigmoid diverticulum with Hounsfield units of 22-36 (red arrow). Hounsfield units of lipomas range from 30 to 70. Figure 1B. 4 cm pedunculated polyp 20 cm from the anal verge. Figure 1C. Microscopy depicting submucosal mass with mature white adipose tissue (red arrow).