Ulcerative colitis or cytomegalovirus colitis in a patient with chronic kidney disease on hemodialysis
DOI:
https://doi.org/10.11606/issn.2176-7262.rmrp.2021.172537Keywords:
Ulcerative colitis, Cytomegalovirus, Chronic kidney disease, ColectomyAbstract
Ulcerative colitis (UC) is a chronic inflammatory bowel disorder affecting the colon and rectum with pathogenesis associated with immune disorders and immunosuppression-based treatment. The immune system of patients on hemodialysis (HD) is suppressed by the uremic environment and the use of immunosuppressives drugs can lead to opportunistic infections such as cytomegalovirus (CMV). CMV infection can lead to relapse or alter the course of UC. This article reports the case of a 42-year-old male patient with chronic kidney disease (CKD) with no defined etiology, in HD for 6 years, without any clinical intercurrence until then, who presented with severe pancolitis, with initial endoscopic and histological diagnosis of UC. He evolved refractory to clinical treatment, being submitted to total colectomy and ileostomy. The microscopic analysis of the surgical specimen revealed in addition to a chronic inflammatory process the presence of atypical endothelial cells suggestive of CMV infection, confirmed by immunohistochemistry. There was a clinical improvement after treatment with ganciclovir. The findings of this patient emphasize the importance of considering the possibility of UC and CMV colitis as a differential diagnosis in patients with CKD in HD who present with fever and bloody diarrhea, especially in those who do not respond to the initial clinical treatment.
Downloads
References
Yamada S, Kanazawa Y, Nakamura N, Masutani K, Esaki M, Kitazono T, Tsuruya K. Ulcerative Colitis Presented as Fever and Bloody Diarrhea at Initiation of Dialysis in an Elderly Patient with End-Stage Kidney Disease. Case Rep Med. 2015;2015. doi:10.1155/2015/725205.
Armstrong MJ, Thomas T, Iqbal T, Boulton R, Goh J. Protracted severe systemic cytomegalovirus disease in an immunosuppressed patient with ulcerative colitis. Frontline Gastroenterol. 2018;9(2):143-147. doi:10.1136/flgastro-2017-100889.
Mourad FH, Hashash JG, Kariyawasam VC, Leong RW. Ulcerative colitis and cytomegalovirus infection: From A to Z. J Crohn’s Colitis. 2020;14(8):1162-1171. doi:10.1093/ecco-jcc/jjaa036.
Da Silva BC, Lyra AC, Rocha R, Santana GO. Epidemiology, demographic characteristics and prognostic predictors of ulcerative colitis. World J Gastroenterol. 2014;20(28):9458-9467. doi:10.3748/wjg.v20.i28.9458.
Ungaro R, Mehandru S, Allen PB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis. Lancet. 2017;389(10080):1756-1770. doi:10.1016/S0140-6736(16)32126-2.
Panaccione R. Mechanisms of inflammatory bowel disease. symptomes and compication. Gastroenterol Hepatol (N Y). 2013;9(8):529-532. http://www.ncbi.nlm.nih.gov/pubmed/24719603%0Ahttp://www.ncbi.nlm.nih.gov/pubmed/24719603.
Głąbska D, Guzek D, Lech G. Nutritional Status of Men with Ulcerative Colitis in Remission in a Pair–Matched Case–Control Study. J Clin Med. 2018;7(11):438. doi:10.3390/jcm7110438.
Conrad K, Roggenbuck D, Laass MW. Diagnosis and classification of ulcerative colitis. Autoimmun Rev. 2014;13(4-5):463-466. doi:10.1016/j.autrev.2014.01.028.
Kume K, Yamasaki M, Yoshikawa I, Harada M. Infliximab treatment in a patient with Crohn’s disease on haemodialysis. Color Dis. 2011;13(3):341-341. doi:10.1111/j.1463-1318.2010.02217.x.
Chiba M, Tsuda S, Tsuji T, Nakane K, Komatsu M, Miura Y, Ishida T, Shibahara T, Nishimoto T. Crohn’s disease successfully treated with infliximab in a patient receiving hemodialysis: Case report and review of the literature. Med (United States). 2014;93(7):1-4. doi:10.1097/MD.0000000000000054.
Kato S, Chmielewski M, Honda H, Pecoits-Filho R, Matsuo S, Yuzawa Y, Tranaeus A, Stenvinkel P, Lindholm B. Aspects of immune dysfunction in end-stage renal disease. Clin J Am Soc Nephrol. 2008;3(5):1526-1533. doi:10.2215/CJN.00950208.
Chen YM, Hung YP, Huang CF, Lee NY, Chen CY, Sung JM, Chang CM, Chen PL, Lee CC, Wu YH, Lin HJ, Ko WC. Cytomegalovirus disease in nonimmunocompromised, human immunodeficiency virus-negative adults with chronic kidney disease. J Microbiol Immunol Infect. 2014;47(4):345-349. doi:10.1016/j.jmii.2013.01.011.
Powell RD, Warner NE, Levine RS, Kirsner JB. Cytomegalic inclusion disease and ulcerative colitis. Am J Med. 1961;30(2):334-340. doi:10.1016/0002-9343(61)90105-X.
Garrido E, Carrera E, Manzano R, Lopez-Sanroman A. Clinical significance of cytomegalovirus infection in patients with inflammatory bowel disease. World J Gastroenterol. 2013;19(1):17-25. doi:10.3748/wjg.v19.i1.17.
Yerushalmy-Feler A, Padlipsky J, Cohen S. Diagnosis and Management of CMV Colitis. Curr Infect Dis Rep. 2019;21(2):1-6. doi:10.1007/s11908-019-0664-y.
Samuel S, Ingle SB, Dhillon S, Yadav S, Scott Harmsen W, Zinsmeister AR, Tremaine WJ, Sandborn WJ, Loftus E V. Cumulative incidence and risk factors for hospitalization and surgery in a population-based cohort of ulcerative colitis. Inflamm Bowel Dis. 2013;19(9):1858-1866. doi:10.1097/MIB.0b013e31828c84c5.
Paul M, Gupta E, Jain P, Rastogi A, Bhatia V. Diagnostic utility of quantitative cytomegalovirus DNA polymerase chain reaction in intestinal biopsies from patients with inflammatory bowel disease. J Lab Physicians. 2018;10(01):038-043. doi:10.4103/JLP.JLP_94_17.
Yadegarynia D, Tehrani S, Roohi M, Gachkar L, Nadji SA, Hashemi M, Molanaei S. Prevalence of cytomegalovirus infection in patients with ulcerative colitis: A prospective cross-sectional study in Tehran, Iran. Iran J Microbiol. 2018;10(5):342-347.
Pal S, Sahni P, Pande GK, Acharya SK, Chattopadhyay TK. Outcome following emergency surgery for refractory severe ulcerative colitis in a tertiary care centre in India. BMC Gastroenterol. 2005;5(1):39. doi:10.1186/1471-230X-5-39.
Rombeau JL, Barot LR, Williamson CE, Mullen JL. Preoperative total parenteral nutrition and surgical outcome in patients with inflammatory bowel disease. Am J Surg. 1982;143(1):139-143. doi:10.1016/0002-9610(82)90144-1.
Travis SP, Farrant JM, Ricketts C, Nolan DJ, Mortensen NM, Kettlewell MG, Jewell DP. Predicting outcome in severe ulcerative colitis. Gut. 1996;38(6):905-910. doi:10.1136/gut.38.6.905.
Downloads
Published
Issue
Section
License
Copyright (c) 2021 Juliana Felizardo Viana, Daniella Bezerra Duarte, Cynthia Paes Pereira, Maria Carolina Santa Rita Lacerda, Yara Janaina Porto Ribeiro, Flora Braga Vaz, Rodrigo Peixoto Campos
This work is licensed under a Creative Commons Attribution 4.0 International License.
