Use of Novel Anticoagulation to Treat Pulmonary Thromboembolism in an Ulcerative Colitis Patient with Cytomegalovirus Superinfection

Abstract

Crohn's disease and ulcerative colitis are the two major types of inflammatory bowel disease, and affect mainly the gastrointestinal tract but also have extraintestinal sequelae, such as arterial and venous thromboembolism. Thromboembolic complications, particularly pulmonary thromboembolism, can be life threatening and require prompt management with anticoagulants. Conventional vitamin K antagonists have been used for the treatment of thromboembolic complications, but the development of novel oral anticoagulants has shifted the paradigm. We report a case of a 42-year-old female with ulcerative colitis with complaints of fever, rectal bleeding, abdominal and chest discomfort of 1-week duration. Initial sigmoidoscopy revealed multiple longitudinal ulcerations with a friable mucosa and easy touch bleeding in all colonic fields. Random biopsies and tissue CMV PCR were performed. The results indicated acute and chronic colitis, together with negative CMV immunohistochemistry, but positive CMV PCR. CMV IgG was positive and CMV real-time PCR using whole blood yielded a viral load of 633 copies/mL (19900 IU/mL). Initial chest dynamic computed tomography (CT) and lower-extremity CT showed diffuse deep vein thrombosis from the left common iliac vein to the calf veins of the lower left leg and filling defects in the lobar and segmental branches of the right lung, suggesting pulmonary thromboembolism. She was treated with oral mesalamine, intravenous steroid and ganciclovir and low-molecular-weight heparin, followed by rivaroxaban, a novel oral anticoagulant. Her symptoms resolved after treatment, and no recurrence was noted during a 6-month post-treatment follow-up.Figure 1Figure 2Figure 3We believe that in the near future, NOACs should replace VKAs for treatment of thrombotic complications in IBD patients.