CMV Pneumonitis in an immunosuppressed IBD patients
R. Stack, V. Parihar, A. Alakkari, B. Ryan
AMNCH, Tallaght, Dublin 24.
Inflammatory bowel disease patients are increasing commenced on immunosuppressant therapies which subsequently puts them at risk of opportunistic infections. This must be kept in mind when approaching the care of immunocomprised IBD patients who may present with either atypical or opportunistic infections. We discuss the case of a 35 year Crohn’s patient who presented with flulike symptoms for one week while on azathioprine therapy.
Cytomegalovirus, CMV, exposure is becoming increasing less frequent due to increasing hygiene conditions. Primary CMV infection while immunosuppressed carries a significantly greater morbidity and mortality. This case highlights the importance in considering primary infection in patient immunosuppressed, particularly where CMV IgM and IgG serology may be unknown, as this is not currently routinely screened in patients commencing azathioprine.
35 year old lady presented with one week history of flulike symptoms of fevers, rigors, arthralgia, and chronic, nonproductive cough. She was on azathioprine therapy for 2 and half years for terminal ileum Crohn's. The patient was febrile, 39.5, tachycardic 126, normotensive and saturating to 98% on room air. She had a normal systemic examination. The patient was treated as a likely viral infection and additionally covered with intravenous co-amoxyclav.
The patient was persistently febrile and became thrombocytopenic. CT abdo-pelvis and colonoscopy showed a normal colon with normal mucosal biopsies. The patient patient developed respiratory distress on day 6 and repeat CXR showed a new right upper lobe lesion. Due to clinical suspicion and patient deterioration, she was started on empirical ganciclovir therapy for CMV pneumonitis and given one dose of G-CSF to treat her leukopenia. CMV IgM and IgG subsequently came back positive suggesting primary infection within 3 months. CMV PCR was 20,205 copies/ml. She required intubation and admission to ICU with haemodialysis. In total she was ventilated for 20 days. Prior to discharge from ICU, she developed a duodenal ulcer complicated by an upper gastrointestinal bleed. She was treated with intravenous proton pump imhibitors.
This case is an example of the risks immunosuppressed patients are exposed to. While CMV colitis is recognised complication regularly considered in unwell IBD patients, CMV pneumonitis is not as common and should be considered early in the differential for a patient with non-localising signs and symptoms. Viral serology prior to commencing azathioprine was unknown. One may argue that if the patient was identified previously as IgM and IgG negative, she would have been flagged high risk for CMV infection earlier.