A simple IBD flare?

33 year old male with ulcerative colitis presents with a 5-day history of fever, night sweats, abdominal pain and increased stool frequency. Medications include mesalazine M/R 1g once daily, 6-mercaptopurine 75mg once daily and a two week course of prednisolone 40mg once daily. Bloods revealed a leukopenia and c-reactive protein of 23. Based on the flexible sigmoidoscopy (figure) findings what is the most likely diagnosis? How would this change your management?

Submitted by Matthew Armstrong, Tom Thomas, Tariq Iqbal, Ralph Boulton and Jason Goh .

Gastroenterology department, University Hospital Birmingham, Birmingham, UK.

  • Andrew Cole

    looks atypical, worry about CMV, any foreign travel? PCR for CMV and if positive ganciclovir.

  • Akshay Gee

    The flexi shows CMV colitis

  • Manos Skouras

    CMV colitis with an inclusion body on histology.
    Start Ganciclovir.
    If no response stop immunosuppression.

  • J Singh

    interesting case, do we have the baseline cmv status?

  • Nikhil Khera

    stop immunosuppressant therapy – and initiate antiviral with ganciclovir

  • Kishaan Jey

    To what degree is he immunosuppressed? 6TG and 6MMP levels?

  • Akhil Khera

    Continue immunosuppressant however begin antiviral therapy. ?CMV Coltis

  • Jakemann

    Cmv colitis. Stop immunosuppression. Check viral titre on pcr. Gangciclovir

  • Dipal Juthani

    The presentation and the sigmoidoscopy appearance of “punched out ulcers” is typical of CMV colitis. Biopsies should be taken for CMV PCR and patient to be treated with IV ganciclovir alongside current treatment.

  • Dev Thanki

    This is an interesting case, and there are some good learning points for me as a medical student. But what findings are demonstrated in figures C and D? It doesn’t seem like anyone has commented on these images yet

  • The symptoms seem to be for Ulcerative Colitis and I would like to add a point that apart from Sigmoidoscopy, the procedure of Colonoscopy can also be done to diagnose the disease. Colonoscopy is the visual examination of the lining of colon and Biopsy can also be done to find the actual problem.
    More info http://bit.ly/2k6CcNk

  • Mandy Yip

    ?CMV colitis. Take biopsies and send for PCR. Contiune immunosuppression and treat with ganciclovir.

  • matthew armstrong

    ANSWER: This case had all the poor prognosticators of CMV in IBD: high initial CMV DNA PCR > 50,000 copies/mL, punched out ulceration on sigmoidoscopy, septicaemia and positive colonic immunohistochemistry for CMV. Despite early discontinuation of immunosuppression, patient required >14 days IV Ganciclovir before signs of clinical improvement (ayprexial etc)

  • matthew armstrong

    ANSWER (Figures): A. stereotypical punched out ulceration B. Histology was pathognomonic of CMV infection with large cells with hyperchromatic nuclei bearing bearing intranuclear basophilic amorphous inclusions surrounded by clear halos (Owl’s eye appearance) C. confirmed with immunohistochemistry D. CT scan revealing colitis, but no evidence of lymphadenopathy (lymphoma excluded).
    Response to blog (Paul richard): Colonoscopy is contraindicated in this setting as patient has acute, severe colitis (high risk of perforation)