IBD 11 EBV reactivation in acute colitis, a management dilemma. (12th September 2022)

• Record Type: Journal Article
• Authors: Ojibara, Zainab; Buxton, Sally; Parmar, Raj; Mukhopadhyay, Anirban
• Is Part Of: Frontline gastroenterology. Volume 13(2022)Supplement 1
• Page Start: A44
• Page End: A44
• Publication Date: 2022-09-12
• Subjects: Gastroenterology -- Periodicals; 616.33005
• DOI: 10.1136/flgastro-2022-bspghan.61
• Languages: English
• ISSNs: 2041-4137

Abstract

Abstract : Introduction: Epstein-Barr Virus (EBV) is one of the most prolific human viruses. It affects people worldwide and has a prevalence of more than 90% in the adult population. Primary EBV childhood infections are often asymptomatic or indistinguishable from other common childhood illnesses. EBV may be reactivated in immunocompromised patients due to its latent characteristics in target cells. IBD patients are at risk through the use of steroids, biologics or both. EBV associated lymphoproliferative disease (LPD) is a feared complication mostly attributed to immunosuppressive agents. Aim: We present a case of EBV reactivation with the presence of EBV on colonic biopsy and highlight the management dilemmas encountered. Subjects: A 15-year-old male with proctitis failed to respond to rectal Mesalazine. He had no other significant past medical or family history and was taking no other regular medications. He presented with increasing bloody stools and weight loss. His height was on the 91st centile and weight had fallen from the 91st to the 75th. He was admitted for Methylprednisolone after failing oral steroid treatment. Re-evaluation was undertaken after 3 weeks of steroid treatment. Results: Ultrasound showed bowel wall thickening in the sigmoid and descending colon. Limited colonoscopy to the descending colon showed continuous inflammation with contact bleeding and mucopus. Microscopic appearances were in keeping with moderate to severe active chronic colitis. Colonic biopsy was negative for CMV but positive for EBV. Blood sampling showed 20, 000 DNA copies of EBV with EBNA antibody detected. EBV IgM was negative and the child had EBV IgG detected at initial diagnosis. There was no evidence of EBV driven lymphoproliferative disorder at that time. This case was managed jointly with Immunology. Reactivation of latent EBV following a prolonged steroid course was the working diagnosis. The family were keen to proceed to colectomy rather than escalate to Infliximab given the long-term risks of lymphoproliferative disorders. Summary: This highlights a case of severe colitis with EBV positivity on biopsy when looking for CMV colitis. CMV testing is unavailable independent of EBV in our trust. Our patient had evidence of prior infection therefore the most likely diagnosis was EBV reactivation. Given colectomy was curative in this case, the family elected for this management option. We have reviewed the literature, which has shown little data in children and no consensus in adults regarding the management of EBV colitis. Immunosuppressive treatments are a significant risk factor for EBV colitis and dose reduction, or cessation can lead to clinical improvement. It is important to exclude lymphoproliferative disease early and ensure understanding of primary infective or reactivated disease. EBV in Crohn's disease will prevent a greater management dilemma, as colectomy will not remove the need for further immunosuppressive treatments. Conclusion: EBV colitis in children is rare with no management consensus. It is associated with a variety of presentations and could cause and/or worsen a flare. The use of immunosuppressant treatment inadvertently puts IBD patients at increased risk of viral reactivation. Management should be multidisciplinary with consideration of the long-term risk of lymphoproliferative disease.