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Objective: We describe a patient with history of heart transplant on maintenance immunosuppression who presented with sigmoid colon perforation from cytomegalovirus (CMV) colitis and performed a systematic review of outcomes after perforated CMV colitis. Background: Cytomegalovirus enterocolitis is uncommon among solid organ transplant patients and can result in small or large bowel perforation. Methods: We systematically reviewed articles describing patients with CMV enterocolitis with small or large bowel perforations from PubMed, Embase, and Web of Science from database inception to February 2021. Results: Seventy-seven articles were identified containing 84 patients with perforated CMV enterocolitis. The most prevalent comorbid diagnosis was human immunodeficiency virus (HIV; 27 patients, 32%), and 37 patients (44%) were taking corticosteroids at time of presentation. The ileum was the most common location for a perforation (26 patients, 31%). Odds of survival were lower for patients with small bowel perforation (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.14-0.98) and HIV/acquired immunodeficiency syndrome (AIDS; OR, 0.32; 95% CI, 0.11-0.88). Odds of survival were higher for patients with large bowel perforation (OR, 2.64; 95% CI, 1.03-7.09), radiographically diagnosed perforation (OR, 3.45; 95% CI, 1.12-11.60) and those who received a CMV antiviral (OR, 9.19; 95% CI, 3.26-28.48). Conclusions: Perforated CMV enterocolitis is uncommon even in immunocompromised hosts. Clinicians should maintain a high level of suspicion for CMV-induced bowel perforation in this population because antiviral treatment is associated with increased odds of survival.

Background/Aims: Infliximab (IFX) has proven effective as rescue therapy in steroid-refractory acute severe ulcerative colitis (ASUC), however, the long-term real-world data are scarce. Our study aimed to assess the long-term treatment outcomes of IFX in a real-life cohort.Methods: We established a multicenter retrospective cohort of hospitalized patients with ASUC, who met Truelove and Witt’s criteria and received intravenous corticosteroid (IVCS) or IFX during index hospitalization between 2006 and 2016 in 5 university hospitals in Korea. The cohort was systematically followed up until colectomy, death or last follow-up visit.Results: A total of 296 patients were followed up for a mean of 68.9 ± 44.0 months. During index hospitalization, 49 patients were treated with IFX; as rescue therapy for IVCS failure in 37 and as first-line medical therapy for ASUC in 12. All patients treated with IFX avoided colectomy during index hospitalization. The cumulative rates of rehospitalization and colectomy were 20.4% and 6.1% at 3 months and 39.6% and 18.8% at the end of follow-up, respectively. Patients treated with IFX presented with significantly shorter colectomy-free survival than IVCS responders (P= 0.04, log-rank test). Both cytomegalovirus colitis and Clostridioides difficile infection (CDI) were the significant predictors of colectomy in the overall study cohort (hazard ratios of 6.57 and 4.61, respectively). There were no fatalities.Conclusions: Our real-world cohort study demonstrated that IFX is an effective therapeutic option in Korean patients with ASUC, irrespective of IFX indication. Aggressive vigilance for cytomegalovirus colitis and CDI is warranted for hospitalized patients with ASUC.

BACKGROUND Cytomegalovirus (CMV) colitis is usually seen in immunocompromised patients with risk factors such as human immunodeficiency virus infection, solid organ transplant, inflammatory bowel disease, or malignancy. Therefore, many clinicians usually do not consider the possibility of CMV colitis in immunocompetent patients. We reported a rare case of segmental colonic hypoganglionosis associated with CMV colitis in an immunocompetent patient. CASE SUMMARY A 48-year-old woman with no underlying disease was admitted to our hospital for severe abdominal pain and constipation. Computed tomography of the abdomen showed diffuse dilatation of the small intestine and the entire colon. Initial sigmoidoscopic findings and result of polymerase chain reaction (PCR) for CMV revealed the compatible findings of CMV colitis, the patient was treated with intravenous ganciclovir. After treatment, sigmoidoscopic findings and CMV PCR results improved. However the patient continued to suffered from constipation. Eight months after the initial admission, patient visited the emergency department with severe abdominal pain and imaging revealed aggravation of fecal impaction and bowel dilatation. We performed subtotal colectomy to control patient’s symptom. Histological examination of the resected specimen showed significantly reduced number of mature ganglion cells in the sigmoid colon compared to that in the proximal colon. CONCLUSION Our case demonstrates that CMV colitis can develop even in patients with no other underlying disease, and that CMV colitis can be one of the causes for developing colonic hypoganglionosis.

Background Elderly-onset inflammatory bowel disease [IBD], defined as age ≥60 at diagnosis, is increasing worldwide. We aimed to compare clinical characteristics and natural history of elderly-onset IBD patients with those of adult-onset IBD patients. Methods Patients with a confirmed diagnosis of IBD from 1981 to 2016 were identified from a territory-wide Hong Kong IBD registry involving 13 hospitals. Demographics, comorbidities, clinical features, and outcomes of elderly-onset IBD patients were compared with those of adult-onset IBD patients. Results A total of 2413 patients were identified, of whom 270 [11.2%] had elderly-onset IBD. Median follow-up duration was 111 months (interquartile range [IQR]: 68–165 months). Ratio of ulcerative colitis [UC]: Crohn’s disease [CD] was higher in elderly-onset IBD than in adult-onset IBD patients [3.82:1 vs 1.39:1; p Conclusions Elderly-onset IBD was associated with increased risk of infections and cancer development, and increased infection- and IBD-related hospitalisations. Specific therapeutic strategies to target this special population are needed.

Cytomegalovirus (CMV) colitis with a cobblestone appearance is rare, and its endoscopic and pathological features remain poorly described. A 78-year-old woman was admitted to our hospital for disturbance of consciousness, high-grade fever, and diarrhea occurring up to 7 times a day. Sigmoidoscopy revealed a circumferential ulcer with mucosal defect, an ulcer with a cobblestone appearance extending from the upper rectum to the sigmoid colon, and an irregular ulcer on the lower rectum. She was histopathologically diagnosed with CMV colitis and intravenously treated with ganciclovir (5 mg/kg) for 7 weeks. Colonoscopy after treatment revealed an improvement of the ulcers extending from the rectum to the sigmoid colon, but no significant improvement of her general condition. She died from sepsis 4 months after hospitalization. To our knowledge, this report represents a valuable addition to the CMV literature describing a rare case of CMV colitis with a cobblestone appearance.

A 64-year-old Japanese man suffered cardiopulmonary arrest, which may have resulted from sepsis and/or hyperosmolar hyperglycemic non-ketonic coma, and was admitted after successful resuscitation. He had watery diarrhea on day 18 and was diagnosed with cytomegalovirus enterocolitis. In addition, computed tomography performed on day 27 and colonoscopy revealed gastric emphysema and intestinal pseudolipomatosis, respectively. This report is the first to describe a patient with cytomegalovirus enterocolitis and subsequent gastric emphysema and pseudolipomatosis. Gastrointestinal cytomegalovirus infection may underlie gastric emphysema and intestinal pseudolipomatosis, particularly in patients with relative or obvious immune dysfunction.

Background: Cytomegalovirus (CMV) is rarely thought to be the cause of significant gastrointestinal infection in immunocompetent children. CMV colitis is seldom observed in young infants. T...

BACKGROUND Data about cytomegalovirus (CMV) colitis in children are scarce. We aimed to describe the characteristics of childhood CMV colitis in terms of risk factors, clinical symptoms, diagnosis, therapeutic approaches, and outcomes. METHODS Inflammatory bowel disease (IBD) and non-IBD patients with CMV colitis diagnosed by histology and tissue CMV PCR at 2 tertiary centers between January 2017 and November 2019 were studied. Clinical and laboratory data were retrieved from medical records. Underlying conditions, immune status, response to therapy and outcomes were described and followed up to 6 months after diagnosis. RESULTS A total of 16 children (8 non-IBD, 7 ulcerative colitis and 1 Crohn's disease) with CMV colitis were included. All patients had persistent diarrhea (bloody in 13 cases). There was a significant age difference between IBD and non-IBD children (P < 0.05). The final diagnosis in 1 patient was immunodeficiency with a mutation in JAK1 gene. Three children were categorized as apparently immunocompromised and 4 children as apparently immunocompetent. Ulcer was not visible in 2 children from the non-IBD group. The mean fecal calprotectin level of IBD children was significantly higher than that of non-IBD children (376.12 ± 231.21 µg/g vs. 160.96 ± 69.94 µg/g, P < 0.05). After follow-up, 1 patient died because of another reason. Ganciclovir was used in 14 of 16 children for 3 weeks and the treatment was continued with valganciclovir in selected 6 children. CONCLUSIONS CMV colitis is a rare but overlooked cause of prolonged diarrhea in immunocompetent and immunocompromised children. CMV colitis might present without any ulcer formation at colonoscopy in infants.

Human immunodeficiency virus (HIV) associated opportunistic infections are complications of patients with advanced HIV infection who are unaware of their disease or non-compliant with antiretroviral therapy. HIV patients with low CD4 count, generally less than 200 cells/μL, are at risk of developing opportunistic infections. We report a case of a 53-year-old male diagnosed with opportunistic infections, Toxoplasma gondii and cytomegalovirus (CMV). His initial presentation was central nervous system Toxoplasmosis and he later developed CMV colitis. Both are consequences of his undiagnosed advanced HIV status. The patient was promptly treated with appropriate medications for both conditions. The patient's HIV status is well controlled with highly active antiretroviral therapy (HAART) and his CD4 count is improving. It further exhibits the significance of adequate screening protocols and the importance of early treatment for HIV patients.

A 68-year-old woman presenting with rheumatoid arthritis was admitted due to pancytopenia caused by methotrexate. Pneumocystis jirovecii pneumonia was diagnosed based on the abnormal shadows observed on chest computed tomography, the presence of serum β-D-glucan, and positive P. jirovecii-DNA results in a sputum analysis. Subsequently, after treatment with leucovorin and trimethoprim-sulfamethoxazole, lung consolidation was found to be aggravated, along with a rapidly increasing leukocyte count. In addition, cytomegalovirus colitis was diagnosed. Both conditions were associated with immune reconstitution inflammatory syndrome caused by recovery from leukopenia. The patient was successfully treated with intravenous methylprednisolone pulse therapy and ganciclovir.

Cytomegalovirus (CMV) is a double-stranded DNA virus member of Herpesviridae family. Majority of the population is exposed to CMV, based on sero-prevalence. CMV establishes latent infection and may re-activate later and cause significant clinical manifestations, especially in immunocompromised patients, like those on immunosuppressant drugs and chemotherapy, post organ transplantation and acquired immunodeficiency syndrome. The clinical manifestations of CMV in immunocompetent people are due to primary infection and vary from mild and self-limiting to severe and debilitating. CMV colitis in immune-competent people is uncommon. The complication of CMV infection leading to colonic perforation and recto-vaginal fistula is rare in immunocompetent subjects. We report case 67 year old female who was admitted with road traffic accident with tibia and T10 vertebral fracture without any abdominal injury. She underwent spinal fixation. She later developed diarrhea with abdominal pain. Whilst investigations were underway, she developed signs of intestinal obstruction. Urgent CT scan of abdomen and pelvis confirmed intestinal obstruction with rectal perforation. Urgent laparotomy was done which confirmed diagnosis of recto-vaginal iula. Adhesiolysis and Hartmanni¯s procedure was performed. Intraoperative biopsy specimen of the rectum confirmed the diagnosis of CMV. She recovered after undergoing rehabilitation and treatment with Ganciclovir. She is awaiting reversal of colostomy.

Background and aims: The impact of cytomegalovirus (CMV) colitis on long-term outcomes of ulcerative colitis (UC) flares remains controversial. Methods: A total of 257 UC patients with moderate-to-severe flares were observed for a mean follow-up of 41.2 months. CMV colitis was defined as histopathologic confirmation of CMV inclusions obtained from macroscopic endoscopic lesions in patients with UC flares. An independent gastrointestinal pathologist prospectively reviewed all specimens. A poor outcome was defined as any of hospitalization, colectomy or death during the follow-up period. Results: The prevalence of CMV colitis was 14% (36/257) over the 10-year study period (2007–2016). When compared to the controls, patients with CMV colitis were characterized by older age, higher disease activity, endoscopic deep ulcerations and more frequent use of immunosuppressive drugs (all p p Conclusions: True CMV colitis is a poor prognostic indicator among patients with UC flares. An effective strategy for managing recurrent CMV colitis is urgently needed (KCT0003296).

Survival outcomes for patients with glioblastoma (GBM) are universally poor with only a small percentage of patients surviving five years beyond initial diagnosis. Activation of the immune system against tumor cells is the basis of immunotherapy and aims to facilitate long-term immune surveillance and tumor suppression. Cytomegalovirus (CMV) has emerged as an immunologic target in GBM given that tumor cells have been shown to express the CMV-associated proteins IE1 and pp65. Moreover, vaccine therapy targeting CMV antigens has promoted improved survival outcomes with long-term survivors. In this report, we present the case of a 69 year-old woman with GBM who survived seven years post-diagnosis. Following tumor resection, the patient underwent concomitant radiation and temozolomide therapy that was complicated by CMV colitis and abdominal abscesses. Despite not receiving adjuvant temozolomide, the patient demonstrated a five year progression-free survival before requiring re-resection for radiation necrosis. Following re-resection, the patient survived for two additional years. As the patient's tumor stained positive for CMV antigens IE1 and pp65, it is hypothesized that she developed an immune response against CMV during recovery that contributed to anti-tumor surveillance and prolonged survival. Overall, this case supports further investigation into the role of CMV and immunotherapy in GBM.

Cytomegalovirus (CMV) infection exists in 50-80% of the world’s population in clinically undetected form due to their immunocompetent status. Here we report a case of a 42-year-old COVID-19 patient with no past medical history, who received tocilizumab, which led to a massive lower gastrointestinal bleeding not responded to medical management.

Introduction: Cytomegalovirus (CMV) is the most common opportunistic agent in HIV-infected patients. It can affect the entire gastrointestinal tract, but frequently involves the oesophagus and the colon. Case Report: We report the case of a 70-year-old female, ultimately diagnosed with HIV infection, whose inaugural clinical manifestation was CMV colitis with endoscopic findings resembling a rectal tumour in which initial histological evaluation was not able to provide a proper diagnosis. Discussion/Conclusion: Since clinical presentation is variable and histopathological yield without immunohistochemical analysis is poor, recognizing CMV infection in the absence of known risk factors may be difficult. It is crucial to consider this entity with suspicious lesions or when initial evaluation, either clinical or histopathological, is inconclusive, thus avoiding potentially debilitating and superfluous treatment or life-threatening complications.

BACKGROUND Cytomegalovirus (CMV) infection is common in individuals with inflammatory bowel disease (IBD) and is responsible for relapse, increased severity, and poor outcome if left untreated. Ganciclovir is the mainstay of treatment but data regarding its use, mode of administration, and duration of treatment is poorly described. We reviewed the practice of treating CMV colitis with different regimes of ganciclovir at a district NHS hospital to compare the clinical outcome. METHODS 35 patients with IBD and concurrent diagnosis of CMV infection were evaluated. The parameters studied were clinical outcome in term of clinical response, length of hospital stay, readmission, or colectomy with three different regimes of ganciclovir, in addition to treatment for IBD. RESULTS 35 patients with IBD (ulcerative colitis = 23, Crohn’s disease = 5, Indeterminate colitis = 7) and positive diagnosis of CMV infection were studied. Clinical outcome with two weeks of intravenous (IV) ganciclovir regime was superior than one week of IV ganciclovir and two weeks of oral Valganciclovir in term of clinical response on day 15 (95.8% vs 74%, 24.3%, respectively p = 0.45) and colectomy rate within 3 months (6.25% vs 27.3%, vs 25%, respectively). CONCLUSION CMV colitis is associated with poor outcome in patient with IBD if left untreated. 2 weeks IV ganciclovir was associated with a better outcome than 1 week of IV treatment or oral treatment.

The case of a female patient with primary membranous nephropathy is presented. She was treated with corticosteroids and chlorambucil after conservative therapy had failed and went into remission for 5 years. Her nephrotic syndrome recurred but did not respond to the same regimen. She had another complete remission after treatment with corticosteroids and cyclosporine, but the nephrosis recurred after 7 years. Again, she failed to respond with retreatment of steroids plus cyclosporine. She was treated with alternate-day steroid plus mycophenolate and, once again, had a complete remission. She was maintained on low-dose mycophenolate for 7 more years. The mycophenolate had to be discontinued because of cytomegalovirus colitis. Treatment with ganciclovir abolished the colitis. She is still in remission 10 years later. The case is discussed with regard to current knowledge of the immune pathogenesis of membranous nephropathy as well as the unknowns of the immunogenesis of the disease.

We investigated the risk factors of and appropriate treatment for cytomegalovirus colitis in patients with ulcerative colitis, using quantitative polymerase chain reaction analysis to detect cytomegalovirus in the colonic mucosa. Between February 2013 and January 2017, patients with exacerbated ulcerative colitis who were admitted to our hospital were consecutively enrolled in this retrospective, single-center study. Patients were evaluated for cytomegalovirus using serology (antigenemia) and quantitative polymerase chain reaction analyses of the colonic mucosa, which were sampled during colonoscopy. Of 86 patients, 26 (30.2%) had positive quantitative polymerase chain reaction results for cytomegalovirus; only 4 were also positive for antigenemia. The ages of the cytomegalovirus DNA-positive patients were significantly higher than those of negative patients (p = 0.002). The mean endoscopic score of cytomegalovirus DNA-positive patients was significantly higher than that of cytomegalovirus DNA-negative patients. Treatment with combined immunosuppressants was associated with an increased risk of cytomegalovirus. Fourteen of 15 (93.3%) cytomegalovirus DNA-positive patients who were negative for antigenemia showed a clinical response to treatment with additional oral tacrolimus, without ganciclovir. cytomegalovirus reactivation in active ulcerative colitis is associated with age and combined immunosuppressant therapy. Because additional treatment with tacrolimus was effective, patients who are negative for antigenemia and cytomegalovirus DNA-positive colonic mucosa may recover without antiviral therapy.

Crohn's disease and ulcerative colitis are the two major types of inflammatory bowel disease, and affect mainly the gastrointestinal tract but also have extraintestinal sequelae, such as arterial and venous thromboembolism. Thromboembolic complications, particularly pulmonary thromboembolism, can be life threatening and require prompt management with anticoagulants. Conventional vitamin K antagonists have been used for the treatment of thromboembolic complications, but the development of novel oral anticoagulants has shifted the paradigm. We report a case of a 42-year-old female with ulcerative colitis who experienced an acute flare-up due to cytomegalovirus superinfection with pulmonary thromboembolism. She was treated with oral mesalamine, intravenous steroid and ganciclovir and low-molecular-weight heparin, followed by rivaroxaban, a novel oral anticoagulant. Her symptoms resolved after treatment, and no recurrence was noted during a 6-month post-treatment follow-up.

Cytomegalovirus infection is an uncommon illness that mainly affects immunocompromised subjects being associated with high morbidity and mortality rates. Reactivation or reinfection of the virus causes various symptoms ranging from asymptomatic forms to severe organ-specific complications, such as severe lower gastrointestinal bleeding. Once diagnosed the infection it is important and necessary to establish an adequate treatment with antivirals, with the surgical option for those cases with gastrointestinal complications depending on the patients clinical situation. We report two cases of immunocompromised patients that after presenting rectal bleeding, were diagnosed of cytomegalovirus colitis, requiring urgent surgery.

Anti-cancer therapy put patients in an immunocompromised status. Reactivation of cytomegalovirus (CMV) in immunocompromised patient can cause a severe disease. Thus, we presented a case who had recurrent CMV colitis which complicate with rectovaginal fistula. We present a case of everolimus-associated cytomegalovirus colitis on a patient receiving everolimus and exemestane therapy for the treatment of metastasized breast cancer. The patient presented septic shock and acute peritonitis at first. Emergency exploratory laparotomy was performed. However, only edematous changes were observed over the terminal ileum, sigmoid colon and rectum. Four weeks after operation, we found feces coming out from her vagina. Colonoscopy was done and revealed rectovaginal fistula. Colonic and rectal mucosa moderate inflammation with multiple ulcer was also noted. Biopsy was done and the pathology proved CMV colitis. After treatment with ganciclovir, her symptoms improved. Everolimus was stopped for 12 weeks and was added back with a decreasing dose paradigm for breast cancer treatment. However, another episode of CMV colitis occurred again after resuming the everolimus. After anti-virus treatment, she was discharged. Due to adverse effects, everolimus therapy was discontinued. The standard treatment of hormone receptor positive and HER-2 negative metastatic breast cancer is everolimus together with exemestane. Due to the immunosuppressive effects of everolimus, the medication may cause invasive fungal infection or other opportunistic infections. Such infections are serious and may even be fatal. In this case, we did not consider CMV infection until rectovaginal fistula formation. Thus, for solid cancer patients presented with fever of unknown origin, clinicians should consider potential complications of CMV infection.

According to current recommendations, in addition to 13-valent pneumococcal conjugate vaccine (PCV13) series, all children with inflammatory bowel disease (IBD) aged ≥2 years, with planned or current immunosuppression, should receive pneumococcal polysaccharide vaccine (PPSV23). The primary aim was to determine the PPSV23 immunization rates in our pediatric IBD patients. The secondary aim was to determine the incidence of invasive pneumococcal disease in these patients. The IBD database at Le Bonheur Children’s Hospital was retrospectively reviewed to identify all cases diagnosed from 2003 to 2015. Out of 190 IBD patients, 106 on immunosuppressive drugs, whose immunization records could be obtained from the state database, were included in the study. Medical records were reviewed to determine infections seen in these patients from the time of diagnosis to date. IBD patients in our study ranged from age 2 to 18 years. Only 4 of 106 (3.7%) patients had received PPSV23 vaccine. Only 1 patient (0.9%) had probable pneumococcal disease and none with invasive pneumococcal disease. Clostridium difficile (11 patients) and Cytomegalovirus colitis (4 patients) were more commonly encountered. All our patients received the recommended PCV13 vaccine. The majority of our pediatric IBD patients did not receive PPSV23 vaccine. Fortunately, we did not see a high rate of invasive pneumococcal disease in our patients suggesting that they may be protected by the primary PCV13 vaccine series. Non-pneumococcal infections were more common in this population.

Cytomegalovirus infection, which can occur as a result of reactivation due to immunosuppressive treatment in patients with granulomatosis with polyangiitis, is a serious condition that should be kept in mind because of its fatal course. In this article, we report a 49-year-old male patient with a diagnosis of granulomatosis with polyangiitis who developed a life-threatening colonic ulcer due to cytomegalovirus colitis and a shrunken spleen with irregular contours that was detected on abdominal computed tomography. This is a rare case of cytomegalovirus disease in a patient with granulomatosis with polyangiitis and splenic necrosis.

BackgroundConcurrent cytomegalovirus (CMV) colitis in inflammatory bowel disease (IBD) and after haematopoietic stem cell transplantation (HSCT) is an important clinical entity associated with high rates of morbidity and mortality.MethodsA retrospective study of 47 patients with IBD and 61 HSCT patients was performed regarding the evaluation of diagnostic accuracy of applied methods, predictors, risk factors for CMV disease manifestation, the proportion of patients with antiviral treatment and disease outcome.ResultsThe sensitivity of quantitative PCR (qPCR) with a cut-off value of >250 copies/mg for CMV colitis in patients with IBD and HSCT patients was 79% and 92%, respectively. Predictors for CMV colitis in the IBD cohort were anaemia and the presence of endoscopic ulcers. Glucocorticoids, calcineurin inhibitors and >2 concurrent lines of treatment with immunosuppressive drugs could be identified as risk factors for CMV colitis in the IBD cohort with an OR of 7.1 (95% CI 1.7 to 29.9), 21.3 (95% CI 2.4 to 188.7) and 13.4 (95% CI 3.2 to 56.1), respectively. Predictors and risk factors for CMV gastroenteritis in the HSCT cohort was the presence of endoscopic ulcers (OR 18.6, 95% CI 3.3 to 103.7) and >2 concurrent lines of treatment with immunosuppressive drugs. Antiviral therapy was administered in 70% of patients with IBD and 77% of HSCT patients with CMV disease. 71% of antiviral-treated patients with IBD showed an improvement of their disease activity and 14% underwent colectomy. The mortality rate of HSCT patients was 21% irrespective of their CMV status.ConclusionsIn addition to the implementation of histological methods, qPCR may be performed in patients with suspected high-risk IBD and HSCT patients for CMV colitis. Independent validations of these results in further prospective studies are needed.

Background Available data on mycophenolate mofetil (MMF), azathioprine (AZA) and methotrexate (MTX) for paediatric-onset anti-N-methyl- d -aspartate receptor encephalitis (anti-NMDARE) is limited. Methods Systematic literature review on patients treated with MMF/AZA/MTX for paediatric-onset anti-NMDARE, with focus on modes of use, efficacy and safety. Results 87 patients were included (age at onset median 11 years, range 0.8–18 years; 69% females). 46% had a relapsing course. 52% received MMF, 27% AZA, 15% MTX, and 6% a combination of MMF/AZA/MTX (7 patients received intrathecal MTX). Before MMF/AZA/MTX, 100% patients received steroids, 83% intravenous immunoglobulin and 45% plasma exchange, and 50% received second-line treatments (rituximab/cyclophosphamide). MMF/AZA/MTX were administered >6 months from onset in 51%, and only after relapse in 40%. Worst mRS before MMF/AZA/MTX was median 4.5 (range 3–5). At last follow-up (median 2 years, range 0.2–8.6), median mRS was 1 (range 0–6). Median annualised relapse rate was 0.4 (range 0–6.7) pre-MMF/AZA/MTX (excluding first events), and 0 on MMF/AZA/MTX (mean 0.03, range 0–0.8). 7% patients relapsed on MMF/AZA/MTX. These relapsing patients had low rate of second-line treatments before MMF/AZA/MTX (25%), long median time between onset and MMF/AZA/MTX usage (18 months), and frequently they were started on MMF/AZA/MTX only after relapse (75%). Relapse rate was lower among patients who received first immune therapy ≤30 days (25%) than later (64%), who received second-line treatments at first event (14%) rather than not (64%), who were started on MMF/AZA/MTX after the first (12%) rather than subsequent events (17%), and who were started on MMF/AZA/MTX ≤3 months from onset (33%) rather than later (53%). Adverse reactions to MMF/AZA/MTX occurred in 2 cases (cytomegalovirus colitis and respiratory infection), of grade 3 Common Terminology Criteria for Adverse Events v4.0. Discussion Our literature review disclosed heterogeneity in the use of MMF/AZA/MTX in paediatric-onset anti-NMDARE. MMF/AZA/MTX usage is mostly restricted to retrospective cohort descriptions. These agents may reduce risk of relapse, and have a reasonable safety profile, however data on larger cohorts are required to definitively determine effect.

We present a case demonstrating the diagnostic work-up of a patient undergoing azathioprine treatment for inflammatory bowel disease (IBD), diagnosed with an acute cytomegalovirus (CMV) infection and CMV colitis. An 18F-FDG positron emission tomography/computed tomography (PET/CT) performed 2 weeks after debut of symptoms revealed pathological 18F-FDG uptake in the left side of the colon mucosa, mimicked activity of IBD. However, a diagnosis of CMV colitis was based on the presence of CMV IgM antibodies, a seroconversion of CMV IgG antibodies, presence of CMV DNA in plasma and the finding af CMV DNA in biopsies from the intestinal mucosa. The patient responded to treatment with ganciclovir. This case highlights that a positive 18F-FDG PET/CT scan of the colon can be due to CMV colitis.

While thalassemia major is a known immunodeficient state, reports of thalassemia minor presenting with immunodeficiency are rare. We present a 66-year-old male with acute abdomen, hemorrhagic colitis, and septic shock. He was diagnosed with coinfection of intestinal tuberculosis and cytomegalovirus colitis secondary to an immunodeficient state due to heterozygous beta-thalassemia.

Background: Cytomegalovirus (CMV) disease affects mainly immunosuppressed individuals such as stem cell and solid organ transplant recipients as well as those patients infected with the human immunodeficiency virus (HIV). Cytomegalovirus colitis has been diagnosed increasingly in normal hosts. Case Presentation: A 65-year-old male with a history of alcohol abuse had been hospitalized for severe bloody diarrhea for three months in an outside hospital; he tested negative for clostridial toxin. He was transferred to our intensive care unit in septic shock and multi-organ failure with bloody diarrhea and a megacolon on computed tomography (CT) scan. Emergency sigmoid colectomy was performed, however, the patient continued to have bloody diarrhea; subsequently, completion sub-total colectomy with ileostomy was performed. On immunohistochemistry a diagnosis of CMV colitis was made; blood CMV polymerase chain reaction (PCR) was positive, the patient tested positive for anti-CMV immunoglobulin (Ig) G but...

Acute cytomegalovirus (CMV) infection occurs commonly in immunocompromised and immunocompetent patients, but is usually asymptomatic in the latter. Vascular events associated with acute CMV infection have been described, but are rare. Hence, such events are rarely reported in the literature. We report a case of pulmonary embolism secondary to acute CMV colitis in an immunocompetent 78-year-old man. The patient presented with fever and diarrhea. Colonic ulcers were diagnosed based on colonoscopy findings, and CMV was the proven etiology on pathological examination. The patient subsequently experienced acute respiratory failure. Pulmonary embolism was diagnosed based on the chest radiography and computed tomography findings. A diagnosis of acute CMV colitis complicated by pulmonary embolism was made. The patient was successfully treated with intravenous administration of unfractionated heparin and intravenous ganciclovir.

A 16-year-old girl presented to our hospital with diarrhea and abdominal pain. The macroscopic findings of colonoscopy revealed multiple submucosal tumors and multiple ulcers, which were localized in the sigmoid colon, and diffuse granular mucosa which extended to the total colon. The pathological diagnosis was malignant lymphoma comprising both components of diffuse large B-cell lymphoma (DLBCL) and mucosa-associated lymphoid tissue (MALT) lymphoma, because the large lymphoma cells were CD20+, CD10-, and CD5-. Furthermore, immunohistochemical analysis of colorectal biopsy samples from multiple ulcers revealed cytomegalovirus (CMV)-positive cells. The patient was diagnosed with primary colorectal lymphoma comprising both components of DLBCL and MALT lymphoma combined with CMV colitis. She received anti-viral medication and chemotherapy.

We herein report the case of a 25-year-old man who was referred to our hospital due to acute cytomegalovirus (CMV) colitis. The initial blood tests showed that the patient had concurrent primary human immunodeficiency virus (HIV) infection and severe thrombocytopenia. Raltegravir-based antiretroviral therapy (ART) was initiated without the use of ganciclovir or corticosteroids and resulted in a rapid clinical improvement. Platelet transfusions were only necessary for a short period, and subsequent colonoscopy revealed a completely healed ulcer. This case implies that ART alone could be effective for treating severe thrombocytopenia during primary HIV and CMV coinfection.

A smouldering adult T-cell leukaemia/lymphoma (ATLL) patient was admitted because of multiple erosions in the colon, which were infiltrated by a mixed population of lymphocytes. PET/CT demonstrated diffuse 18F-Fluorodeoxyglucose accumulation in the whole colon accompanied by multiple lymph node swelling. Histological examinations of lymph node suggested aggressive transformation to lymphoma type of ATLL. However, the general condition worsened with extremely elevated LDH, cytomegalovirus pp65 and sIL-2R after the administration of prednisolone. By contrast, subsequent administration of ganciclovir with tapered prednisolone ameliorated the laboratory findings. Differential diagnosis for aggressive ATLL and serious cytomegalovirus infection is needed.

A 68-year-old man visited an emergency department complaining of dyspnea. He was diagnosed to have Legionella pneumonia with multiple organ failure. Although his multiple organ failure improved, he suffered from persistent abdominal pain and diarrhea with continuous minor bleeding. Colonoscopy revealed a longitudinal ulcer of the rectum, below the peritoneal reflection. He was diagnosed with cytomegalovirus (CMV) colitis. Antiviral therapy with ganciclovir was initiated. He finally underwent a colostomy after a bowel stricture caused an intestinal outlet obstruction, which made oral intake impossible. Based on the present case, we believe that CMV colitis must be considered as one of the differential diagnoses when critically ill patients develop continuous diarrhea and abdominal pain.

Cytomegalovirus (CMV) colitis usually affects immunocompromised hosts. We report a patient with type 2 diabetes mellitus who presented with massive lower gastrointestinal bleed due to CMV colitis, which proved to be fatal. Awareness about this life-threatening entity is important in patients who have impaired immune response.

Cytomegalovirus (CMV) is a common cause of colitis, particularly in immunosuppressed patients. Rarely, CMV can present as a mass lesion that endoscopically appears consistent with adenocarcinoma. There are no reported cases of a CMV mass lesion inducing rectal prolapse. We present a case of CMV colitis presenting as a rectal mass mimicking adenocarcinoma and causing rectal prolapse in an immunosuppressed female.

SESSION TITLE: Fellows' COVID-19 SESSION TYPE: Fellow Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Interleukin-6 (IL-6) drives the inflammatory response in patients with Covid-19 infection and can sometimes present as cytokine storm Sarilumab, an IL-6 inhibitor may have the potential for reducing the overactive inflammatory immune response associated with the COVID-19 virus The potential complications of this experimental treatment in this setting are still unknown CASE PRESENTATION: 64-year-old man with coronary artery disease and obesity was admitted for Covid-19 pneumonia He received a 5-day course of hydroxychloroquine and azithromycin His inflammatory markers continued to worsen and his clinical picture was concerning for cytokine storm He received sarilumab, an IL-6 inhibitor He was started on empiric broad-spectrum antibiotics for a presumed bacterial superinfection His hospital course was complicated by renal failure requiring renal replacement therapy He also received convalescent plasma on day 17 Given prolonged intubation, the patient underwent tracheostomy placement on day 25 On day 26, the patient’s tracheostomy tube had become dislodged resulting in cardiac arrest with successful cardiopulmonary resuscitation The patient was noted to have rectal bleeding on day 33 with subsequent colonoscopy revealing ischemic colitis Biopsies of the colon revealed cytomegalovirus (CMV), and he was started on ganciclovir This finding was concerning that the use of an IL-6 inhibitor, in addition to his acute illness, had placed him at an increased risk of CMV infection DISCUSSION: No prospective studies have yet specifically assessed covid-19 superinfections in the setting of IL-6 inhibitor use It is well reported in the literature that critically ill patients are susceptible to CMV infection and may be associated with poor outcomes (1) The common adverse drug reactions seen in clinical trials for sarilumab include upper respiratory tract and urinary tract infections, as well as neutropenia and increased liver function tests (2) As covid-19 proceeds, more literature is reported on IL-6 as an important marker of inflammation to recognize severe covid-19 disease, thus prompting the use of IL-6 inhibitors (3) Prospective studies are needed to evaluate data on superinfections and outcomes regarding the use of IL-6 inhibitors in critically ill patients infected with covid-19 To our knowledge, this is the first reported case of CMV colitis due to IL-6 inhibitor administration in the setting of covid-19 infection CONCLUSIONS: IL-6 is a marker of inflammation that has been used as a reference during the covid-19 pandemic in order to guide the use of IL-6 inhibitors Randomized prospective trials to assess clinical outcomes are needed in order to provide guidelines regarding IL-6 inhibitors use in covid-19 infection Reference #1: Osawa R, Singh N Cytomegalovirus infection in critically ill patients: a systematic review Critical Care 2009, 13:R68 Reference #2: McCarty D, Robinson A Efficacy and safety of sarilumab in patients with active rheumatoid arthritis Ther Adv Musculoskel Dis 2018,10(3) 61–67 Reference #3: Aziz M, Fatima R, Assaly R Elevated Interleukin-6 and Severe COVID-19: A Meta-Analysis Journal of medical virology 28 April 2020 DISCLOSURES: No relevant relationships by Nasheena Jiwa, source=Web Response No relevant relationships by Kiran Lorick, source=Web Response No relevant relationships by Rahul Mutneja, source=Web Response