Poster (15W202)

Thiopurine therapy is associated with severe symptomatic primary CMV infection in patients with inflammatory bowel disease

Author(s)

Catherine Rowan, Ciaran Judge, Garret Cullen, Hugh E. Mulcahy, Glen A. Doherty

Department(s)/Institutions

St.Vincent's University Hospital, Dublin

Introduction

CMV disease is observed in patients with inflammatory bowel disease (IBD), generally related to reactivation. Primary Cytomegalovirus (CMV) infection is traditionally believed to be uncommon in adults due to high population seroprevalence. The nature of the relationship between CMV and IBD has been a matter of debate since it was first described in 1961 by Powell and is made more complicated by the use of immunomodulators, such as Azathioprine.

Aims/Background

The aim of this study was to examine the frequency and severity of primary CMV infection in adult IBD patients.

Method

A retrospective review of a prospectively maintained database of 3,200 IBD patients attending a single academic centre was performed. Patients with Primary CMV infection between 2010 and 2013 were identified using CMV IgG avidity indices; clinical, serologic and virologic parameters were studied in detail. The seroprevalence of CMV in the patient population was also then evaluated based on pre-immunosuppresion screening serology.

Results

Seroprevalence for CMV, indicating prior exposure, in our IBD population was estimated at 30.5% and increased with age. Eight patients with IBD (UC=3, IBD-U=1, CD=4) presented with acute primary CMV infection (patients with CMV reactivation were excluded); 4 patients presented with colitis, 2 with respiratory CMV, 1 with CMV hepatitis and 1 systemic CMV infection. Median age was 33 years and median duration of disease was 72 months. All eight patients were receiving a thiopurine immunomodulator (IM) at the time of presentation.7 patients were neutropenic at admission but had no preceding neutropenia or deranged LFTs to indicate drug toxicity. Median duration of IM use was 144 weeks (range 7-720 weeks). All patients required hospitalisation (ICU admission, n=1); the median length of hospital stay was 15.5 days (range 6-27), with no statistically significant difference in the colitis subgroup. (p=0.41) Infection resolved in all cases with withdrawal of IM and/or antiviral therapy and 3 patients subsequently resumed their immunomodulator therapy.

Conclusions

This study highlights the impact primary CMV infection can have in IBD patients, particularly those on immunomodulators. Patients with primary CMV can present in a multitude of ways and it is associated with considerable morbidity. CMV prevalence in our IBD cohort is relatively low at 30%, but is in keeping with data from peri-natal screening in Ireland. In an era of increasingly aggressive medical therapy and low CMV seroprevalence , physicians should be cognisant of primary CMV as a potential cause of deterioration in IBD patients.