Toxic megacolon and human Cytomegalovirus in a series of severe ulcerative colitis patients

Abstract

a b s t r a c tBackground: Human Cytomegalovirus (HCMV) infection has been reported to be a cause of refractory ulcerative colitis (UC). Toxic megacolon (TM) is a rare but severe complication of an acute attack of UC. Objectives: Aim of this study is to evaluate in a case-control study the association between HCMV and TM. Study design: All patients who were admitted at Medicine Department of V. Cervello Hospital in Palermo (tertiary referral center) for a severe UC flare-up complicated by the onset of TM (diameter of the transverse colon > 6 cm) between January 1990 and November 2011 were identified through the electronic database. A total of 24 consecutive patients (16 male/8 female) with TM were identified. Each case of TM were individually matched by sex, age, extent of the underlying disease to 24 severe UC controls who did not develop TM. A further non matched control population of 48 severe UC was included.Haematoxilin and eosin stain, immunohistochemical procedure and nested polymerase chain reaction were performed to detect HCMV genes and proteins on rectal biopsies or surgical specimens. Pp65 antigenemia was performed in order to diagnose any possible systemic infection. HCMV frequency was compared between patients with and without TM during follow-up, using Fisher's Exact test. Results and conclusions: HCMV was detected in histological specimens of 11 patients (46%) with TM compared to 2 (9%) severe UC matched controls (P = 0.0078) and 7 (14%) unmatched controls (p = 0,003). In severe colitis the presence of HCMV is more frequently associated with TM.

High mucosal cytomegalovirus DNA helps predict adverse short-term outcome in acute severe ulcerative colitis

“…10 Prevalence of CMV has also been correlated with severity of ASUC as evidenced significantly higher prevalence of CMV in patients with toxic megacolon than those without (46% vs. 9%). 29 In the present study, IHC positivity and mere positivity for mucosal CMV DNA was not predictive of steroid nonresponse. However, high CMV DNA load of > 2,000 copies/mg was able to predict steroid failure with a reasonable diagnostic accuracy, having a sensitivity of 53% and specificity of 90%.…”

Management of Paediatric Ulcerative Colitis, Part 2

“…Case reports indicate potential effectiveness of infliximab (171–173), leukocytapheresis (174), tacrolimus (175,176), or hyperbaric oxygen (177) for treating toxic megacolon, but the evidence is anecdotal. Although CMV infection is more commonly associated with toxic megacolon, there is not enough evidence to support empiric treatment with ganciclovir without confirmation of CMV infection (178).…”

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

“…In patients with prior exposure to immunosuppression, endoscopy should also be used to exclude cytomegalovirus (CMV) colitis . Identification of multiple intranuclear inclusion bodies on haematoxylin and eosin staining is a reliable means of identifying CMV colitis, but diagnosis may require immunohistochemistry . Colonoscopy has been evaluated in acute severe colitis but is not recommended because of the risk of perforation or precipitating toxic dilatation .…”

“…The majority of patients with toxic megacolon are diagnosed on admission. Many patients with IBD who develop toxic megacolon will have underlying secondary gastrointestinal infection . Management is the same as for acute severe colitis with the addition of intravenous antibiotics to cover microbial translocation and emergency colectomy in selected cases.…”