Reactions 1704, p197 - 2 Jun 2018 Colonic perforation secondary to cytomegaloviral colitis and cytomegaloviral infection: case report A 69-year-old man developed colonic perforation secondary to cytomegaloviral colitis and cytomegaloviral infection following treatment with cyclophosphamide, methotrexate, methylprednisolone and prednisone [not all routes stated]. The man, who was diagnosed with upper airways-limited granulomatosis with polyangiitis in 2009 and treated with prednisone 5 mg/day and methotrexate 20 mg/week, was admitted to the hospital due to acute kidney injury. On admission, his laboratory examinations were found significant for increased creatinine level, mild anaemia, proteinurea, haematuria and an elevated antineutrophil cytoplasmic antibody (PR3-ANCA) titre. His renal biopsy showed rapidly progressive necrotising granulomatous glomerulonephritis. As a result, he received IV pulse-dose methylprednisolone 1 g/day for three days, followed by oral prednisone 1 mg/kg, followed by cyclophosphamide pulse 1g (to be repeated once a month for six months) as induction remission therapy. His systemic symptoms resolved; however, renal function did not improve. He was discharged with prednisone 50 mg/day with gradual tapering and also received cotrimoxazole [trimethoprim- sulfamethoxazole] for prophylaxis of Pneumocystis jirovecii. On day 40, he was admitted to receive second pulse of cyclophosphamide as planned. Before the admission, he reported a 3 day history of abdominal pain (hypogastric, right lower quadrant pain) and constipation. On admission, blood tests results revealed increased CRP, procalcitonin and creatinine. However, PR3-ANCA level found to be decreased. Concomitant hypogammaglobulinemia [aetiology not specified] was also noted. An abdominal X-ray showed small- bowel distension and right sub-diaphragmatic free gas. Emergent CT scan confirmed the sub-diaphragmatic free gas and revealed a pelvic gas-fluid collection due to sigmoid diverticular perforation. He underwent emergent laparotomy with sigmoid resection, closure of the rectal stump and colostomy, along with on-table lavage due to incipient diffuse purulent peritonitis. The peritoneal surface appeared dull and reddened. Macroscopic examination of the resected specimen demonstrated colonic ulceration with free perforation. Histology confirmed transmural ulceration. Scattered cells immunoreactive for CMV were identified within the mixed inflammatory infiltrate bordering the mucosal defect. A PCR testing in plasma for quantification of CMV DNA was found positive. The man received antiviral therapy with valganciclovir, along with broad-spectrum antibiotics amoxicillin/clavulanic-acid including fluconazole for fungal disease prophylaxis. His PR3 antibody levels normalised within the following 2 months while prednisone was reduced to 25mg daily. Three months later, CMV DNA was found negative. Cotrimoxazole and decreased dose of valganciclovir was subsequently given until a month after the 6th cyclophosphamide infusion. Rituximab was then started as maintenance therapy and repeated every 6 months. One year after the colonic perforation, he was independent of dialysis with creatinine levels of 2.0 mg/dL and he showed no features of recurrent CMV disease or CMV viremia. His GPA was in remission and colostomy was ongoing [not all outcomes stated]. Author comment: "We reported the case of a patient affected with . . . colonic perforation due to [cytomegalovirus] colitis a few weeks after immunosuppressive treatment with high-dose steroids and cyclophosphamide (CYC) for remission induction of the disease." "Immunosuppressive drugs represent the gold standard for the treatment of major organ involvement in [granulomatosis with polyangiitis] patients, with a significant risk for opportunistic infections." Soriano A, et al. Colonic perforation due to severe cytomegalovirus disease in granulomatosis with polyangiitis after immunosuppression. Clinical Rheumatology 37: 1427-1432, No. 5, May 2018. Available from: URL: http://doi.org/10.1007/ s10067-017-3945-6 - Italy 803323906 0114-9954/18/1704-0001/$14.95 Adis © 2018 Springer International Publishing AG. All rights reserved Reactions 2 Jun 2018 No. 1704
Reactions Weekly – Springer Journals
Published: Jun 2, 2018
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