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Puo-Hsien Le,1,2 Chia-Jung Kuo,1–3 Ren-Chin Wu,3,4 Jun-Te Hsu,3,5 Ming-Yao Su,1–3 Chun-Jung Lin,1,3 Cheng-Tang Chiu1–3 1Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; 2Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan; 3College of Medicine, Chang Gung University, Taoyuan, Taiwan; 4Department of Pathology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; 5Department of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan Background: Cytomegalovirus (CMV) colitis typically presents in immunocompromised and inflammatory bowel disease (IBD) patients. Several studies have been conducted on the endoscopic characteristics of CMV colitis in IBD patients. Objectives: The endoscopic findings of CMV colitis in non-IBD patients and their relationship with inhospital mortality are unclear. We aimed to describe the endoscopic presentation in these patients and to determine the endoscopic predictors of inhospital mortality. Patients and methods: Patients with CMV colitis diagnosed using histology between April 2002 and December 2016 at the Linkou Chang Gung Memorial Hospital, Taiwan, were retrospectively enrolled. Patients diagnosed with IBD during follow-up were excluded. Patient data, including underlying diseases, endoscopic presentation, laboratory data, clinical course, complications, and clinical outcomes, were collected. The independent risk factors for inhospital mortality were analyzed with logistic regression. The difference of overall survival was compared using Kaplan–Meier survival curve and log rank test. All statistical calculations were performed using SPSS software, version 21. Results: Sixty-nine patients were enrolled, and 8 IBD patients were excluded. Within the 61 non-IBD patients, 31 were diagnosed by colonoscopy and others by sigmoidoscopy. Ulceration (77%) was the most common endoscopic finding, followed by a cobblestone appearance (19.7%), colitis with/without erosions (9.8%), pseudomembrane (9.8%), and tumor/polyp-like lesions (8.2%). Among the patients who underwent full-length colonoscopy, 35.3% presented with right-sided colitis, 23.5% with left-sided colitis, and 32.4% with pancolitis. Pancolitis was identified as a negative predictor of inhospital mortality (odds ratio, 6.8; 95% confidence interval, 1.233–37.497; p=0.028) and overall survival (log rank p=0.018). Conclusion: Colonoscopy is recommended for precise CMV colitis diagnosis and outcome prediction in non-IBD patients. Keywords: cytomegalovirus colitis, CMV, inflammatory bowel disease, endoscopy, colonoscopy, mortality

Longitudinal mucosal and submucosal hemorrhage along the taeniae coli is a potential colonic manifestation of cytomegalovirus infection in immunocompromised patients. When diagnosing cytomegalovirus colitis in immunocompromised patients, endoscopic biopsy on taeniae coli seems effective for viral detection.

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.

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 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.

Background Historically, cytomegalovirus (CMV) infection in immunocompetent patients has been considered to have a relatively indolent and self-limited course, not warranting specific treatment. Case presentation We are presenting a 72-year-old African-American male transferred to our intensive care unit (ICU) with methicillin-resistant Staphylococcus aureus bacteremia, respiratory failure, and dialysis-dependent acute kidney injury. While he recovered from bacteremia, he remained difficult to wean from respiratory support, had labile blood pressure, and manifested persistent diarrhea. Stool antigen testing for C. difficile colitis returned repeatedly negative. Flexible sigmoidoscopy described diffuse ulceration, attributed to ischemic colitis. The colon biopsy specimen, however, described tissue-invasive cytomegalovirus (CMV) infection. Polymerase chain reaction (PCR) testing confirmed viremia with 8,900 copies/mL viral DNA. Human immunodeficiency virus antibody and PCR testing were both negative. Absolute lymphocyte count varied between 80 and 450/mm3 during the admission. After IV ganciclovir initiation, diarrhea and respiratory failure resolved, while renal function recovered to the patient'€™s baseline. Conclusion The combination of critical illness and recent bacteremia likely represented a state of profound immunosuppression in this formerly healthy patient. CMV colitis may be under-diagnosed in sick ICU patients with renal failure and otherwise unexplained diarrhea. Serum PCR testing may aid the diagnosis.

BACKGROUND: Severe Cytomegalovirus (CMV) colitis is a rare condition, most commonly seen in immunocompromised patients. We describe a case of CMV colitis masquerading as recurrent ischemic colitis in a patient with end-stage renal disease (ESRD). AIMS: Describe a case of severe CMV colitis presenting as recurrent ischemic colitis. METHODS: Case report RESULTS: Case: A 44 year-old man with atherosclerotic risk factors including hypertension, diabetes mellitus, ESRD on hemodialysis and morbid obesity presented twice to our emergency department (ED) within 14 days with hematochezia, acute abdominal pain, fever, leukocytosis, and an elevated serum lactate. Computed tomography scan of the abdomen (CT-Abdo) demonstrated changes consistent with isolated right colon ischemia (IRCI). Colonoscopy showed circumferential ulcerated mucosa with greyish discoloration and sloughing of the mucosa starting at the hepatic flexure and extending proximally, potentially due to ischemic colitis (figure 1). There was a sharp demarcation between the normal and ulcerated mucosa, and, in view of possible ischemia, the endoscope was not introduced further. A colonic biopsy at the edge of demarcation was taken and showed non-specific small ulcerations. The patient improved with conservative management including intravenous fluids and antibiotics. He was discharged home with resolution of symptoms. He unfortunately returned to our ED two weeks later with a third episode of hematochezia, abdominal pain and hemorrhagic shock. Repeat CT-Abdo showed persistent IRCI with new pneumatosis intestinalis. As he failed to improve with vasopressors, blood transfusions, and antibiotic therapy, an urgent right hemicolectomy was performed. On pathology, multiple CMV organisms were identified with ulcerations and perforation, consistent with severe CMV colitis. CMV PCR was only minimally elevated (80copies/mL). IV ganciclovir was initiated. On follow-up visit, the patient demonstrated sustained clinical improvement, and no recurrence of symptoms. CONCLUSIONS: IRCI is an uncommon form of ischemic colitis, but occurs more frequently in patients with significant atherosclerosis and hemodialysis. Despite initial improvement, the patient’s symptomatic recurrence was initially attributed to his severe vasculopathy, coupled with ongoing hemodialysis causing fluid shifts. In a review of the literature of 14 cases with ESRD and CMV GI disease, 72% presented with lower GI bleeding, colonoscopy showed ulceration or polypoid lesions, and was associated with a 35% mortality. CMV colitis should be suspected in atypical cases of ischemic colitis, and early diagnosis may avoid significant morbidity. FUNDING AGENCIES: None

Cytomegalovirus (CMV) colitis usually occurs in patients with advanced immunosuppression when the CD4 count is

Background Graft versus host disease (GVHD) is a rare complication following liver transplantation (LT) and has high mortality. We describe our single-center experience with 6 cases of GVHD diagnosed over a period of 14 years in a total of 604 liver transplant recipients--283 deceased donor liver transplants (DDLT) and 321 living-related liver transplants (LDLT). Case report We report a case series of 6 patients with acute GVHD after liver transplantation from May 2001 to December 2014. Five cases were males; age 51-67 years (average 61). The time from transplantation until clinical presentation of GVHD ranged from 36 to 140 days, with average duration of 72 days. All cases had diarrhea and pancytopenia, 4 out of 5 presented with erythematous skin rashes, and 2 had cytomegalovirus colitis. GVHD was confirmed by skin biopsies, engraftment profile from bone marrow biopsy, and sigmoid colon biopsy. Treatment strategies included use of corticosteroids in 4 cases, stopping immunosuppression in 1 case, and no treatment in 1 case with mild disease. Five patients died between 18 to 65 days from clinical presentation (average 43 days) and 1 patient with mild GVHD is doing well 290 days after clinical presentation. Conclusions GVHD is a rare complication after liver transplantation that needs a high index of suspicion in patients who develop rash, diarrhea, or sever pancytopenia. There is no consensus on the best treatment regimen and mortality remains high.

Managing mild-to-moderate ulcerative colitis on the first view appears to be a simple task. However, real life often proofs the opposite and creates a challenging situation. In theory, mild-to-moderate disease should be sufficiently treated by mesalamine or alternatively by a probiotic. Insufficient treatment comprises the danger of leading to a flare, and hence, an exacerbation of the entire disease, with risk of progressing to severe disease. What are the considerations with regard to patient management in this situation? Certainly, disease distribution is the critical information, since it allows for planning the optimal route of administration, namely local versus systemic treatment. Novel pharmacological strategies might allow for reaching high local concentrations even at the left side of the colon or alternatively administer locally active budesonide throughout the entire colon frame, thus avoiding systemic side effects. Therapy planning has to involve the patient to identify how this can be included in daily life. Including the patient implies that depending on the condition, disease activity and even life quality, the individual therapy requires timely adaption. A recent study by Pedersen et al. [Inflamm Bowel Dis 2014;20:2276-2285] provides evidence that this strategy can be followed and leads to an overall better outcome. A last thought, besides the patient not taking the appropriate dose or lacking adherence to therapy, should consider that a worsening of disease could be due to infectious complications including Clostridium difficile or cytomegalovirus colitis. If all considerations fail within a reasonable time frame, therapy should be escalated. Patients in this situation often hesitate in accepting the need of immunosuppression. Future options, potentially including phosphatidylcholine, might bridge the gap between mesalamine, probiotics and immunosuppressive strategies.

The aim of the pictorial review are to review the HIV manifestations within the gastrointestinal tract. We have detailed five conditions, with reference to the patients’ CD4 count – gastrointestinal tuberculosis, Kaposi’s sarcoma, small bowel lymphoma, cytomegalovirus colitis and anal carcinoma.

Although graft-versus-host disease (GVHD) is the major complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT), cytomegalovirus (CMV) reactivation also occurs in patients after allo-HSCT and these conditions often clinically overlap. The aim of this study was to determine reliable endoscopic findings of CMV colitis in patients with gastrointestinal graft-versus-host-disease (GI-GVHD). Patients after allo-HSCT who were histologically confirmed to have GI-GVHD with or without CMV colitis and patients with an immunosuppressive condition were retrospectively analyzed. We divided the patients into three groups: GI-GVHD with CMV colitis (group A), GI-GVHD without CMV colitis (group B), and CMV colitis without undergoing allo-HSCT (group C). From medical records, the involved colorectal areas and endoscopic findings according to the groups were compared. A total of 70 patients were divided into three groups (group A: n = 19, group B: n = 28, group C: n = 23). Mucosal injuries in groups A and C frequently occurred in the cecum including ileocecal valves. On the other hand, there were no abnormal lesions on ileocecal valves in group B. Furthermore, ulcer lesions were more frequently observed in groups A and C than in group B (p

We report the first case of a ganciclovir-resistant cytomegalovirus (CMV) involving the gastrointestinal tract that was successfully treated with high-dose valganciclovir. A kidney transplant recipient developed drug-resistant CMV colitis which was initially treated with valganciclovir, but his CMV was found to have major resistance to ganciclovir and cidofovir due to UL97 and UL54 mutations. The patient was switched to intravenous foscarnet 40 mg/kg given every twelve hours. However, foscarnet had to be discontinued after 4 days of treatment due to acute kidney injury. Patient was restarted on valganciclovir at a higher target dose of 1800 mg twice a day based on the creatinine clearance. CMV became undetectable 2 weeks after valganciclovir treatment was completed. High-dose valganciclovir along with immune suppression reduction may be a treatment option for CMV colitis with ganciclovir resistance due to dual UL97 and UL54 gene mutations.

Severe ulcerous cytomegalovirus pancolitis developed during primary human immunodeficiency virus (HIV) infection in a patient who underwent early combination antiretroviral treatment. This massive inflammatory process led to acute colon perforation. Serological testing demonstrated cytomegalovirus reactivation. Severe immunosuppression caused by primary HIV infection resulted in cytomegalovirus colitis, and initiation of early combination antiretroviral therapy triggered an immune reconstitution inflammatory syndrome potentially leading to colonic perforation.

Cytomegalovirus (CMV) is a double-stranded DNA virus that is associated with clinically significant disease in patients with advanced immunosuppression, particularly those with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). End-organ disease with CMV is classically associated with a CD4 cell count less than 50 cells/microliter. CMV colitis is the second most common manifestation of end-organ disease in this patient population. CMV-associated enteric fistula is a rare complication that has been described in only a few case reports in the literature. These cases describe gastrocolic, enterocutaneous, enterocolic, rectovaginal, and colocutaneous fistulae. However, colovesical fistula has not been described previously. Here, we report the first case of CMV-associated colovesical fistula in a patient with HIV infection and AIDS.

The novel coronavirus-2019 (COVID-19) has caused a global pandemic of historical proportions, infecting millions of people worldwide. Due to its high mortality rate and a paucity of clinical data, experimental therapies have been utilized with uncertain success and, unfortunately, poor outcomes. We describe a gentleman who was treated with experimental therapies and subsequently developed cytomegalovirus colitis and hypovolemic shock. Additionally, this case validates colonoscopy as a mode to rule out concurrent infectious etiologies causing diarrhea in COVID-19-positive patients.

Background Complications from graft-vs.-host disease (GVHD), a major contributor to morbidity and mortality following hematopoietic cell transplantation, may be mitigated by early diagnosis and intervention. However, differentiation between acute cutaneous GVHD and other common skin eruptions that develop in the post-transplantation period, such as drug hypersensitivity reaction, can be challenging clinically and microscopically. Because recent evidence indicates that CD123, a marker of plasmacytoid dendritic cells, can help to distinguish gastrointestinal GVHD from the clinicopathologic mimic cytomegalovirus colitis, we aimed to determine whether CD123 could aid in the diagnosis of acute cutaneous GVHD. Methods We studied 12 skin specimens of patients with grades I–II cutaneous GVHD and 12 from patients who had drug hypersensitivity reaction with vacuolar interface changes on biopsy. Results No differences were seen between the two groups with regards to density or distribution of CD123 expression. Specimens representing GVHD showed significantly less spongiosis (P < 0.001) and fewer dermal eosinophils (P = 0.03) compared to those representing drug hypersensitivity reaction. Conclusions We conclude that CD123 does not appear to be a useful ancillary test in the diagnosis of acute cutaneous GVHD. Careful correlation between clinical findings and features with microscopy remains the cornerstone of accurate diagnosis of acute cutaneous GVHD.

Background Patients with cytomegalovirus (CMV) colitis have increasingly been recognized among critically ill patients, yet few specific clinical and endoscopic features are known. In this study, we investigated the common clinical and endoscopic features of CMV colitis in critically ill patients. Methods From January 1, 2000 to February 28, 2014, patients with a histopathological diagnosis of CMV colitis were retrospectively reviewed. We reviewed and analyzed the clinical presentation, primary diseases, serum CMV antibody, treatment, mortality, and endoscopic features of these patients. Results Eighteen patients were diagnosed as having CMV colitis and 15 CMV colitis patients were included in this study. The mean age was 65.7 years (range 42–92 years). Bloody diarrhea and persistent diarrhea were the most common initial presentations of CMV, and sepsis was the most common comorbidity found. CMV-IgM was positive in three (17%) patients, and CMV-IgG was positive in 14 (93.3%) patients. All patients received ganciclovir and 11 patients clinically improved. Four (26.6%) patients died and two patients had colon perforation. According to the severity of the diseases, endoscopic presentation of CMV colitis ranged from colonic mucosa edema, loss of vasculature, subepithelial hemorrhage, and circular or geographic ulcers to perforation. Ten (66.7%) patients had multiple ulcers and five (33.3%) patients had a single ulcer. Eleven (73.3%) patients had colitis involving distal to splenic flexure, and four (26.6%) patients had colitis involving the whole colon. Conclusion Critically ill patients who present with bloody stool or persistent diarrhea should be considered for the diagnosis of CMV colitis. The endoscopic presentation of CMV colitis is highly variable. We suggest that the endoscopic manifestation of CMV colitis can be divided into three stages: nonulcerative inflammatory stage, simple ulcerative stage, and complicated ulcerative stage.

The role of cytomegalovirus (CMV) reactivation in the outcome of inflammatory bowel diseases (IBDs) is unclear. Uncertainties remain on the treatment of CMV infection, especially in patients with a viral load just above the normal value in the blood or with very few positive cells in colonic biopsies. This retrospective cohort study reports the long-term outcome of 38 active IBD patients with CMV infection, 13 of whom received an antiviral treatment.Thirty patients with ulcerative colitis (UC) and eight patients with Crohn's colitis with active colitis and CMV infection, diagnosed by detection of at least one CMV inclusion by histology and immunohistochemistry and/or with the CMV antigen test or the CMV DNA test, were studied. Their clinical history at 6 months and up to 1 year following hospital discharge was reviewed. Clinical remission at hospital discharge and recurrences requiring new treatments or colectomy were considered major outcomes of the study. The features of treated and untreated patients were compared using the Fisher exact test and the Student t-test.All patients showed rare CMV inclusions, and only three had positive blood CMV PCR. Thirteen patients received antiviral treatment, whereas 25 patients did not. No patient underwent colectomy during the hospitalization. The 12-month cumulative rate of clinical relapse requiring new treatment or colectomy was 23% in patients treated with antivirals and 50% in untreated patients (P=0.165). However, in patients with UC and in those with steroid-dependent/refractory disease, antiviral treatment was associated with a significantly higher clinical remission rate at 12 months (77.8 vs. 45%, P=0.049, and 77.8 vs. 19.4%, P=0.038, respectively).In IBD patients with active CMV colitis, antiviral treatment seems to have a marginal impact in the short term, during the treatment of the acute phase, but it may have some beneficial effect in maintaining remission up to 1 year of follow-up in patients with UC and steroid-dependent/refractory disease.

Cecal bascule is a rare type of volvulus of the colon and requires a mobile cecum and ascending colon, which could be due to congenital or acquired anatomic abnormalities. Inflammatory conditions that cause acute changes in colonic mobility or motility may contribute to development of volvulus, as described in other types of colonic obstruction. Patients with risk factors for a mobile proximal colon presenting with obstructive symptoms should undergo prompt diagnostic evaluation for volvulus to allow for timely intervention. We report an unusual case of invasive cytomegalovirus colitis presenting as cecal bascule in a kidney transplant recipient.

BackgroundThe immune reconstitution inflammatory syndrome (IRIS) in HIV-infected infants and young children is relatively understudied in regions endemic for HIV and TB. We aimed to describe incidence, clinical features and risk factors of pediatric IRIS in Sub-Saharan Africa and India.Methods and findingsWe conducted an observational multi-centred prospective clinical study from December 2010 to September 2013 in children ConclusionsIRIS occurs commonly in HIV-infected children initiating ART and occasionally has severe morbidity. The incidence may be underestimated. Predictive, diagnostic and prognostic biomarkers are needed.

The prevalence of cytomegalovirus in the burn population is high. However, its role in the clinical management of burn patients is still being defined. This report documents a 41-year-old man who developed cytomegalovirus (CMV) colitis after being admitted with a 72% burn. Before the administration of ganciclovir, the authors had difficulty controlling his quantitative wound cultures with serial debridements, topical agents, and systemic antibiotics for known pathogens, which led to graft loss. After the ganciclovir was given, his quantitative wound cultures improved without changing the authors' topical agents or systemic antibiotics and had improved graft take. Whether CMV infection alone contributed to an increased morbidity in this patient or the combination of bacteria/fungal infection with CMV led to a synergistic effect is still not clearly understood. CMV may have contributed to a dysfunction in his cell mediated immunity, which, in turn, lowered the bacterial and fungal load necessary to cause graft loss. Patients who continue to do poorly despite adequate treatment for known pathogens may need to be screened for CMV and treated.

Cytomegalovirus (CMV) is a common pathogen worldwide. Clinically significant CMV infection is mostly seen in the context of immunosuppression, whether congenital, acquired, or iatrogenic. In the recent past, however, in both adults and children, an increasing number of moderate-to-severe cases of colitis have been described among immunocompetent patients. We describe a rare case of severe CMV colitis in an immunocompetent patient which resolved spontaneously.

Cytomegalovirus (CMV) infection is often seen in immunocompromised patients. Rarely, immunocompetent patients may present with CMV as a self-limiting, flu-like illness, though a few cases of significant organ-specific complications have been reported in these patients. We report a case in which a previously healthy man presented with hematochezia and an obstructing rectal mass thought to be rectal adenocarcinoma. Biopsy was positive for CMV, which was treated with full resolution of rectal mass confirmed with colonoscopy and barium contrast enema. This is the first reported case of CMV colitis mimicking rectal adenocarcinoma in an immunocompetent patient.

Colitis is the most common extraocular manifestation of cytomegalovirus (CMV) infection in human immunodeficiency virus (HIV) infected patients. CMV disease is usually seen in HIV-infected patients with CD4+ counts less than 50/ mm 3 . There are documented reports of CMV gastrointestinal disease in patients with CD4+ count greater than 50 cells/L. A 46-year-old man with HIV1 infection on irregular antiretroviral treatment presented with low grade fever, abdominal pain and vomitings. He is a known alcoholic. Physical examination revealed pallor, evidence of malnutrition and tenderness in the abdomen. Laboratory investigations revealed mild anaemia; CD4+ count was 240 cells/L. Fundus examination of the patient was normal. Contrast enhanced computed tomography (CECT) of the abdomen revealed dilated small bowel loops, thickening of wall of splenic flexure and thickening of caecal and terminal ileal wall with mild narrowing. As anti-CMV antibodies (IgM) and CMV real time-polymerase chain reaction (PCR) tested positive, patient was treated with intravenous ganciclovir for 14 days followed by oral valganciclovir and patient showed remarkable improvement. Our case highlights the fact that CMV colitis can also occur in patients with relatively preserved CD4+ counts especially if co-morbid conditions like alcoholism co-exist.

The efficacy of hematopoietic stem cell transplantation (HSCT) is greatly hampered by graft-versus-host disease (GVHD) and opportunistic infection; the gastrointestinal tract is one of the main target organs involved by GVHD and opportunistic infectious agents. The presence of crypt apoptosis is the major criterion for the histologic diagnosis of GVHD; however, it can also be seen in infection, especially cytomegalovirus (CMV) colitis. Therefore, the definitive histopathologic diagnosis of GVHD in gastrointestinal tract can be challenging or impossible without reliable ancillary markers. We studied the expression of CD123 and C4d in 38 colonic biopsies from patients with HSCT with acute GVHD and 14 colon biopsies from patients with CMV colitis without history of HSCT. CD123 expression was significantly increased in the acute GVHD group compared with the CMV group (65.8% versus 14.3%; P.05) with increasing sensitivity in higher-grade GVHD (grades 1-2, 60%; grades 3-4, 72.2%). However, there was no significant difference in C4d deposition between the acute GVHD and CMV groups (68.4% versus 42.9%; P.05). We further applied CD123 immunostaining to upper gastrointestinal (n = 23) and colonic biopsies (n = 24) in patients with HSCT without evidence of acute GVHD or infection and 11 biopsies from patients who had used mycophenolate. The negative staining of CD123 in all these cases further supports the specificity of CD123 in acute GVHD. In summary, CD123 might be a useful ancillary marker to aid in separating infection from GVHD in patients with HSCT.

The role of infliximab in the treatment of patients with ulcerative colitis (UC) in Asia is still unclear. The aim of this study was to evaluate the clinical outcomes of infliximab therapy in Korean UC patients, including efficacy and predictors of response. Patients who received infliximab induction therapy for moderate to severe UC at Asan Medical Center were retrospectively analyzed. The demographic characteristics of these patients and their clinical outcomes following infliximab therapy were evaluated. Of the 89 UC patients receiving infliximab induction therapy, 53 (59.6 %) were steroid-refractory and 36 (40.4 %) were steroid-dependent. At the initiation of infliximab, the median Mayo score was 9 (range 7–12). After the induction therapy of infliximab, 59 patients (66.3 %) demonstrated a clinical response at week 8, of which 29 (32.6 %) were determined to be in clinical remission. A colectomy was performed within 1 year after infliximab initiation in 11 (36.7 %) of 30 patients who displayed no clinical response to infliximab therapy, but in none of the 59 patients who showed a response to this drug (p

Background Cytomegalovirus (CMV) is frequently detected in ulcerative colitis (UC) lesions of steroid-refractory patients. This has led to the suspicion that CMV might cause colitis and steroid refractoriness. Methods During 2003 and 2011, 187 consecutive patients were divided into group I (n = 105), corticosteroid-free and thiopurine-free in the past 6 months, and group II (n = 82), all corticosteroid refractory. The combination of serum CMV immunoglobulin (Ig)M, CMV IgG, CMV antigenemia (Ag), and real-time polymerase chain reaction assays were performed to identify CMV(+) patients. Results In group I, 79 patients were CMV IgG(+) and 26 patients were CMV IgG(-) and CMV IgM(-). In group II, 61 patients were CMV IgG(+), 1 CMV IgM(+), and 20 CMV IgG(-) and CMV IgM(-). All CMV IgG(+) patients were screened for CMV Ag. In group I, 6 of the 79 CMV IgG(+) patients were CMV Ag(+). In group II, 27 patients were CMV Ag(+). Colonoscopy was performed in all patients before screening for CMV. Similar colonoscopic features including punched out ulcers, geographic ulcers, and irregular ulcers were found in both CMV(+) and CMV(-) patients, without any striking difference between the 2 groups. Conclusions CMV reactivation might be encouraged by immunosuppressive drugs, like corticosteroids, immunomodulators, and therefore, patients with UC are at a high risk of CMV reactivation, potentially exacerbating UC. However, this study of 187 patients, CMV(+) and CMV(-), could not find colonoscopic features unique to CMV, except that CMV might be one factor for steroid refractoriness, and UC exacerbation.

Cytomegalovirus (CMV) colitis is a common entity in immunocompromised patients, being rare among immunocompetent individuals. In addition, its association with ischemic colitis is unusual in both groups of population. Rectal bleeding might occur in both entities and, occasionally, urgent surgical treatment may be required, associating high morbility rates. We report one case of cytomegalovirus colitis associated with severe ischemic colitis in a non- immunocompromised patient with favourable response to conservative management with antiviral therapy.

We report a case of hemorrhagic cytomegalovirus (CMV) colitis, occurring in a postoperative patient due to a weakened immune system. An 85-year-old woman with a medical history, including chronic renal failure treated with oral administration of prednisolone, underwent colectomy due to an ascending colon cancer. While the postoperative course was favorable, she exhibited acute severe abdominal pain and massive bloody discharge after 11 days of surgery. Her colonoscopic examination showed multiple longitudinal ulcers on the anastomosis. In addition to these endoscopic findings, her past medical history helped suggest CMV colitis. Because serological testing revealed positive CMV antigen, she was finally given a diagnosis of CMV colitis and received intravenous ganciclovir for the initial treatment. Hemorrhagic CMV colitis after colectomy is an important postoperative complication; we therefore present our case with diagnosis and treatment experience.

We report a case of HIV-associated Cytomegalovirus colitis complicated by large bowel perforation. A 62-year-old man of same-sex relationship was not known to have HIV, but a diagnosis of inflammatory bowel disease was made early in his admission, with steroid treatment initiated. He was later confirmed to be HIV positive, and found to have multiple microperforations of the bowel necessitating ileocecectomy and Hartmann's procedures.

Cytomegalovirus colitis is common in immunocompromised patients, but rare in immunocompetent patients. The present study not only represents the colonoscopy and pathological findings, but also applies the method of diagnosing and treating cytomegalovirus colitis in immunocompetent patients.

Cytomegalovirus latency, though ubiquitous in the human population, is known to cause colitis in both immunocompromised and immunocompetent hosts. Furthermore, the clinical, endoscopic, and histologic appearance of cytomegalovirus colitis can mimic that of inflammatory bowel disease, an extremely well-documented disease. In this context, though many reports have looked at inflammatory bowel disease with superimposed cytomegalovirus infection, less attention has been paid to cytomegalovirus as a primary cause of isolated colitis. Owing to the rarity of this phenomenon, it is important to consider this diagnosis and implement proper testing to avoid misdiagnosis and mismanagement.

When we examine a patient with symptoms of acute enteritis in the course of chemotherapy with oral fluoropyrimidines such as uracil-tegafur (often referred to as UFT), we usually suspect 5-fluorouracil-induced enterocolitis. In case of persistent clinical symptoms despite discontinuation of chemotherapy, cytomegalovirus colitis should be considered in the differential diagnosis of chemotherapy-induced enterocolitis. We herein report the case of a patient who underwent surgery for lung adenocarcinoma followed by postoperative adjuvant chemotherapy with uracil-tegafur and was diagnosed as having cytomegalovirus colitis during the therapy. In the course of chemotherapy, cytomegalovirus colitis occasionally occurs even though the patient does not experience severe myelosuppression; thus, it is necessary that we recognize its potential occurrence.

Epstein-Barr virus (EBV)-positive mucocutaneous ulcer (EBVMCU) is a newly described entity occurring in elderly or iatrogenically immunocompromised patients. We describe a case of EBVMCU arising in a post-hematopoietic cell transplant patient and followed by EBV-positive polymorphic posttransplant lymphoproliferative disorder (EBV+ polymorphic PTLD). The patient, a 52-year-old woman, received chemotherapy and autologous peripheral blood stem cell transplantation for relapsed diffuse large B-cell lymphoma (DLBCL). She achieved complete remission and was followed up in an outpatient clinic after discharge. One year later, EBVMCU appeared in the tongue and exhibited spontaneous regression. Six months after the regression of the EBVMCU, she had EBV+ polymorphic PTLD, analogous to EBV+ polymorphic DLBCL. The therapy for PTLD was not effective, and the patient finally died of disease progression. This was the first case of EBVMCU characterized by both an association with autologous peripheral blood stem cell transplantation and subsequent emergence of malignant lymphoma in a patient with relapsed DLBCL.

5.1 General When deciding the appropriate treatment strategy for active ulcerative colitis one should consider the activity, distribution (proctitis, left-sided, extensive1), and pattern of disease. The disease pattern includes relapse frequency, course of disease, response to previous medications, side-effect profile of medication and extra-intestinal manifestations. The age at onset and disease duration may also be important factors. #### 5.1.1 Disease activity The principal disease activity scoring systems used in clinical trials are covered in Section 1.2 and have been comprehensively reviewed.2 However there are some practical points that are relevant for routine clinical use. For example, it is most important to distinguish patients with severe ulcerative colitis necessitating hospital admission from those with mild or moderately active disease who can generally be managed as outpatients. The simplest, best validated and most widely used index for identifying severe UC remains that of Truelove and Witts3: any patient who has a bloody stool frequency ≥ 6/day and a tachycardia (> 90 bpm), or temperature > 37.8 °C, or anaemia (haemoglobin 30 mm/h) has severe ulcerative colitis (Table 1.3). Only one additional criterion in addition to the bloody stool frequency ≥ 6/day is needed to define a severe attack.4,5 It should be standard practice to confirm the presence of active colitis by sigmoidoscopy before starting treatment. Flexible sigmoidoscopy and biopsy may exclude unexpected causes of symptoms that mimic active disease such as cytomegalovirus colitis, rectal mucosal prolapse, Crohn's disease, malignancy, or even irritable bowel syndrome and haemorrhoidal bleeding. There may be a significant overlap between other diseases that mimic ulcerative colitis and the broad spectrum of UC damage.6,7 In addition, all patients with active disease require stool cultures with Clostridium difficile toxin assay to exclude enteric infection. Patients with an appropriate …

We herein report a case of a 67-year-old diabetic woman who presented with a history of fatigue for 1 month. Her investigations showed proteinuria, active urine sediment, p-ANCA positivity and worsened renal functions. A diagnosis of rapidly progressive glomerulonephritis was made. Renal biopsy revealed class V (membranous) lupus nephritis with superimposed ANCA-associated crescentic glomerulonephritis. She was treated with steroids and cyclophosphamide. Two months later, she presented with cytomegalovirus colitis and deep vein thrombosis of right leg. The case reflects an interesting renal pathology, and complications of the disease per se and its treatment.