Abstract
Pouchitis is a frequent complication of surgical treatment of ulcerative colitis (UC), and is typically treated using antimicrobials. If pouchitis is refractory to antimicrobials, screening for complications, such as cytomegalovirus (CMV) infection, is necessary. However, the optimal approach to management of pouchitis complicated by CMV infection is unclear. We report the case of a 41-year-old female patient with UC presenting with pouchitis associated with CMV infection; she had received subtotal colectomy/ileal pouch anal anastomosis (IPAA). She was admitted to hospital with persistent fever, epigastric discomfort, and watery diarrhea despite receiving antibiotics. Laboratory findings showed inflammation and reactivation of CMV infection accompanied by liver injury. The endoscopic findings showed inflammation of the pouch and ileal mucosa on the oral side with extensive and deep punched-out ulcers. Immunohistological staining of biopsy specimens from an ulcerated lesion demonstrated CMV infection. Therefore, we diagnosed the patient with pouchitis complicated by CMV infection. The patient was treated with ganciclovir and infliximab, which resolved her symptoms and led to the disappearance of CMV-positive cells. There has been no recurrence of pouchitis. CMV infection should be considered in patients with UC who develop refractory pouchitis.
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References
Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012;142:46–54.
da Silva BC, Lyra AC, Rocha R, et al. Epidemiology, demographic characteristics and prognostic predictors of ulcerative colitis. World J Gastroenterol. 2014;20:9458–67.
Hwang JM, Varma MG. Surgery for inflammatory bowel disease. World J Gastroenterol. 2008;14:2678–90.
Pardi DS, Sandborn WJ. Systematic review: the management of pouchitis. Aliment Pharmacol Ther. 2006;23:1087–96.
Sandborn WJ, Pardi DS. Clinical management of pouchitis. Gastroenterology. 2004;127:1809–14.
Ogawa H, Fukushima K, Sasaki I. Pouchitis Nihon Shokakibyo Gakkai Zasshi. 2009;106:996–1002.
Stahlberg D, Gullberg K, Liljeqvist L, et al. Pouchitis following pelvic pouch operation for ulcerative colitis Incidence, cumulative risk, and risk factors. Dis Colon Rectum. 1996;39:1012–8.
Shepherd NA, Hulten L, Tytgat GN, et al. Pouchitis. Int J Colorectal Dis. 1989;4:205–29.
Herfarth HH, Long MD, Isaacs KL. Use of Biologics in Pouchitis: A Systematic Review. J Clin Gastroenterol. 2015;49:647–54.
Uchino M, Ikeuchi H, Bando T, et al. Clinical Features of Refractory Pouchitis with Penetrating Lesions and the Efficacy of Infliximab Treatment for Patients with Ulcerative Colitis after Restorative Proctocolectomy. Digestion. 2015;92:147–55.
Navaneethan U, Shen B. Secondary pouchitis: those with identifiable ethiopathogenetic or triggering factors. Am J Gastoenterol. 2010;105:51–64.
McCurdy JD, Loftus EV, Tremaine WJ, et al. Cytomegalovirus infection of the ileoanal pouch: clinical characteristics and outcomes. Inflamm Bowel Dis. 2013;19:2394–9.
Araujo Miguez A, Herrera Justiniano JM, Carnerero EL, et al. Pouchitis associated with cytomegalovirus infection: a case study. Inflamm Bowel Dis. 2013;19:E65–6.
Pillet S, Pozzetto B, Roblin X. Cytomegalovirus and ulcerative colitis: place of antiviral therapy. World J Gastroenterol. 2016;22:2030–45.
Nakase H, Chiba T. TNF- α is an important pathogenic factor contributing to reactivation of cytomegalovirus in inflamed Mucosa of colon in Patients with ulcerative colitis: Lesson from clinical experience. Inflamm Bowel Dis. 2010;16:550–1.
Carter MJ, Di Giovine FS, Cox A, et al. The interleukin 1 receptor antagonist gene allele 2 as a predictor of pouchitis following colectomy and IPAA in ulcerative colitis. Gastroenterology. 2001;121:805–11.
Sehgal R, Berg A, Hegarty JP, et al. NOD2/CARD15 mutations correlate with severe pouchitis after ileal pouch-anal anastomosis. Dis colon rectum. 2010;53:1487–94.
Lammers KM, Ouburg S, Morre SA, et al. Combined carriership of TLR9-1237C and CD14-260T alleles enhances the risk of developing chronic relapsing pouchitis. World J Gastroenterol. 2005;11:7323–9.
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Masahiro Yanagi, Takuya Komura, Takashi Kagaya, Takatoshi Yoshio, Michiko Nishino, Noriaki Orita, Masashi Nishikawa, Atsuhiro Kawashima, Shuichi Kaneko, Masashi Unoura declare that they have no conflict of interest.
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Yanagi, M., Komura, T., Kagaya, T. et al. A case of refractory pouchitis complicated by cytomegalovirus infection requiring administration of ganciclovir and infliximab. Clin J Gastroenterol 14, 181–186 (2021). https://doi.org/10.1007/s12328-020-01289-z
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DOI: https://doi.org/10.1007/s12328-020-01289-z