To Treat Or Not To Treat? Dilemma Of Cmv Ileitis And Biologic Therapy

Cytomegalovirus (CMV) enterocolitis is an infection often associated with significant immunosuppression We report a case of CMV ileitis in a healthy male who subsequently was diagnosed with Crohn's disease. Guidance for treatment of active CMV disease prior to initiation of biologic therapy is lacking in the current medical literature, outside of chemotherapy guidelines. A 43-year-old African American male was referred to the Gastroenterology clinic for a 12-month history of alternating diarrhea and constipation and newly decreased stool caliber. Colonoscopy was unable to be initially performed due to a significant anal stricture. Exam under anesthesia demonstrated a functional narrowing of the anus as well as two large ulcers of the posterior anal canal. Biopsies demonstrated granuloma formation along with positive staining for CMV. Repeat colonoscopy demonstrated extensive circumferential ulcerations and inflammation of the terminal ileum (TI) with endoscopically normal colon. Biopsies from the TI demonstrated chronic ileitis with positive CMV staining. MRE confirmed extent of newly diagnosed Crohn's disease and he underwent a 21-day course of valganciclovir prior to initiation of biologic therapy. CMV ileitis is rare in young, immunocompetent patients without significant co-morbidities such as diabetes or end-stage kidney disease. Current medical literature is limited in guidance regarding treatment of active CMV disease prior to initiation of biologic therapy; existing guidelines only relate to treatment prior to chemotherapy. NCCN guidelines recommend screening and treatment of CMV infection prior to immunosuppressive treatments due to the risk of disseminated CMV after starting chemotherapy. Disseminated CMV can be a significant complication of biologic therapy and we should consider anti-viral therapy prior to initiation.2054_A Figure 1. 20x CMV…: H&E stain of an anal biopsy at 200x magnification demonstrates loose granulomatous inflammation and a characteristic CMV inclusion (arrow).2054_B Figure 2. 40x CMV…: Immunohistochemistry for CMV demonstrates scattered positive cells (dark brown).2054_C Figure 3. Endoscopic view of terminal ileum demonstrating extensive circumferential ulcerations and inflammation