Abstract
We report a rare case of peristomal pyoderma gangrenosum with severe gastroduodenal lesions, developing after total colectomy in a patient with ulcerative colitis and concomitant cytomegalovirus (CMV) enteritis. A 19-year-old man underwent total proctocolectomy with an ileal J-pouch anal anastomosis and diverting ileostomy, after 2 years of ineffective medical treatment. On postoperative day 6, severe peristomal pyoderma gangrenosum developed and progressed rapidly. Maintaining immunosuppressive therapy with corticosteroids for 6 days induced melena from the gastroduodenal lesions and enteritis with concomitant CMV reactivation. The patient required a jejunostomy, after the duodenal and intestinal CMV lesions had caused multiple perforations. Treatment with intensive cytapheresis was ineffective against the associated UC lesions, which healed with infliximab induction. The CMV reactivation was treated effectively with ganciclovir. The patient is being maintained on infliximab every 8 weeks and there has been no sign of recurrence of the gastroduodenitis-associated UC and CMV reactivation.
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Rubenstein J, Sherif A, Appleman H, Chevy WD. Ulcerative colitis associated enteritis: is ulcerative colitis always confined to the colon? J Clin Gastroenterol. 2004;38:46–51.
Annese V, Caruso N, Bisceglia M, Lombardi G, Clemente R, Modola G, et al. Fatal ulcerative panenteritis following colectomy in a patient with ulcerative colitis. Dig Dis Sci. 1999;44:1189–95.
Sasaki M, Okada K, Koyoma S, Yoshioka U, Inoue H, Fujiyama Y, et al. Ulcerative colitis complicated by gastroduodenal lesions. J Gastroenterol. 1996;31:585–9.
Hori K, Ikeuchi H, Nakono H, Uchino M, Tomita T, Ohda Y, et al. Gastroduodenitis associated with ulcerative colitis. J Gastroenterol. 2008;43:193–201.
Papadakis KA, Tung JK, Binder SW, Kam LY, Abreu MT, Targan SR, et al. Outcome of cytomegalovirus infections in patients with inflammatory bowel disease. Am J Gastroenterol. 2001;96:2137–42.
Matsuoka K, Iwao Y, Mori T, Sakuraba A, Yajima T, Hisamatsu T, et al. Cytomegalovirus is frequently reactivated and disappears without antiviral agents in ulcerative colitis patients. Am J Gastroenterol. 2007;102:331–7.
Kishore J, Ghoshal U, Ghoshal UC, Krishnani N, Kumar S, Singh M, et al. Infection with cytomegalovirus in patients with inflammatory bowel disease: prevalence, clinical significance and outcome. J Med Microbiol. 2004;53:1155–60.
Okita Y, Miki C, Yoshiyama S, Otake K, Araki T, Uchida K, et al. Neutrophil dysfunction in steroid-overdosed patients with ulcerative colitis: potential relevance of macrophage migration inhibitory factor to increased postoperative morbidity. Surg Today. 2011;41:1504–11.
Kambham N, Vij R, Cartwright CA, Longacre T. Cytomegalovirus infection in steroid refractory ulcerative colitis: a case–control study. Am J Surg Pathol. 2004;28:365–73.
Sakamoto I, Shirai T, Kamide T, Igarashi M, Koike J, Ito A, et al. Cytomegalovirus enterocolitis in an immunocompetent individual. J Clin Gastroenterol. 2002;34:243–6.
Cotte L, Drouet E, Bissuel F, Denoyel GA, Trepo C. Diagnostic value of amplification of human cytomegalovirus DNA from gastrointestinal biopsies from human immunodeficiency virus infected patients. J Clin Microbiol. 1993;31:2066–9.
Minami M, Ohta M, Ohkura T, Ando T, Ohmiya N, Niwa Y, et al. Cytomegalovirus infection in severe ulcerative colitis patients undergoing continuous intravenous cyclosporine treatment in Japan. World J Gastroenterol. 2007;13:754–60.
Greenstein AJ, Janowitz HD, Sachar DB. The extra-intestinal complications of Crohn’s disease and ulcerative colitis: a study of 700 patients. Medicine. 1976;55:401–12.
Funayama Y, Kumagai E, Takahashi K, Fukushima K, Sasaki I. Early diagnosis and early corticosteroid administration improves healing of peristomal pyoderma gangrenosum in inflammatory bowel disease. Dis Colon Rectum. 2009;52:311–4.
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Uchino, M., Ikeuchi, H., Bando, T. et al. Diffuse gastroduodenitis and enteritis associated with ulcerative colitis and concomitant cytomegalovirus reactivation after total colectomy: report of a case. Surg Today 43, 321–324 (2013). https://doi.org/10.1007/s00595-012-0329-z
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DOI: https://doi.org/10.1007/s00595-012-0329-z