Cytomegalovirus in ulcerative colitis: an evidence-based approach to diagnosis and treatment

ABSTRACT

Introduction

The detection of cytomegalovirus (CMV) in the setting of inflammatory bowel disease often creates confusion whether CMV is a ‘bystander’ or ‘disease.’

Areas Covered

This review discusses the clinical conundrum of CMV in ulcerative colitis, approach to discriminate infection from disease, and therapeutic considerations (immunosuppressive and anti-CMV treatment). CMV disease should be considered in corticosteroid refractory- dependent and thiopurine refractory disease. Endoscopy may reveal deep punched out ulcers, irregular ulcers, or cobble-stoning. The diagnosis rests on the presence and abundance of viral inclusion bodies on hematoxylin and eosin stain, positive immunohistochemistry, and/or positive tissue polymerase chain reaction. CMV disease is associated with worse outcomes including increased colectomy rates.

Expert Opinion

The timing and duration of antiviral drugs in CMV disease is debatable but depends on the load of CMV in tissue. In high-grade infection, CMV needs to be treated while increasing immunosuppression may work in the setting of low-grade infection. Ganciclovir is the drug of choice for treatment of CMV disease. Tumor necrosis factor inhibitors may be useful for treating underlying disease activity in the setting of CMV. Other emerging therapies include fecal microbiota transplantation. Randomized studies are necessary to define the best timing and duration of anti-CMV therapy.

KEYWORDS:

• Ulcerative colitis
• inflammatory bowel disease
• colectomy
• thiopurine
• steroids
• ganciclovir

Article highlights

• All patients with steroid refractory or dependent disease and thiopurine refractory disease should be evaluated for CMV disease.

• CMV infection is usually recognised by the presence of viral inclusion bodies on hematoxylin and eosin stain and/or positive immunohistochemistry in histopathology.

• Quantitative CMV PCR is useful in evaluating the burden of CMV in the tissue and may help in the diagnosis of CMV disease.

• In low-grade CMV infection, it may be better to target the underlying disease activity with immune suppression.

• In high-grade CMV infection, antiviral therapy should be considered while tapering of steroids and thiopurines.

Declaration of interests

A Jena’s position as Senior Research Associate is supported by CSIR, Government of India, New Delhi, India. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Supplementary material

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