UC, CMV, PE, Why Me?

Abstract

Introduction: Patients with ulcerative colitis (UC) are at risk for complications including CMV colitis and thromboembolic disease. CMV complicating UC typically occurs in severely active or steroidrefractory colitis. Thromboembolic events in UC are usually associated with disease flares and steroid use. We present a case of systemic CMV infection and thromboembolism in a patient with previously quiescent UC. Case Description: A 42-year-old woman with pancolonic UC presented with 2 weeks of fever, shortness of breath, constipation and rectal bleeding. Her UC had been in clinical, endoscopic and histologic remission on infliximab, 6-mercaptopurine (6MP) and mesalamine. She elected to discontinue infliximab 6 months prior to presentation and remained asymptomatic. Two weeks after travelling to Indonesia, she experienced the onset of fevers, constipation, and later, scant hematochezia. An evaluation for infectious causes was negative. Due to progressive symptoms, the patient returned to the USA and a sigmoidoscopy revealed ulcerative proctitis limited to the distal 5cm of the rectum. She was hypotensive and hypoxemic and was referred to the emergency department (ED) for further evaluation. In the ED, she was febrile to 103.7o F with a WBC of 3.6 with lymphopenia and a hemoglobin of 10.7. AST and ALT were elevated at 38 and 51. A CT of the chest showed multiple pulmonary emboli (PE). Rectal biopsies showed mild chronic active proctitis with CMV. Serum CMV IgM and IgG were positive. A plasma CMV DNA PCR was elevated at 5074. She was admitted to the hospital for anticoagulation and symptomatic treatment. She received IV gancyclovir and SQ low molecular weight heparin, and was transitioned to valgancyclovir and rivaroxaban on discharge. 6MP was discontinued and infliximab was restarted. On follow-up, her fevers, cytopenias, liver enzyme abnormalities and hematochezia had resolved. Discussion: CMV colitis and thromboembolism complicating severe UC are well described in the literature. This patient developed systemic CMV reactivation and bilateral PE with only limited proctitis, no recent UC flare and no steroid use. CMV reactivation with systemic manifestations is a rare occurrence, but should be considered in UC patients who have systemic symptoms out of proportion to the activity of their colitis. This case also highlights the multiple interacting risk factors (including CMV infection itself) for PE in patients with UC.