2090 EBV Colitis With Fulminate Ulcerative Colitis: A Clinical Dilemma

INTRODUCTION: Epstein-Barr virus (EBV) is a virus of the herpes family. EBV can be detected in the gastrointestinal tissue of patients with inflammatory bowel disease(IBD). However, the clinical significance of EBV colitis in ulcerative colitis (UC) is unclear. We present an interesting and rare case of EBV colitis in a patient with fulminant UC. CASE DESCRIPTION/METHODS: A 73-year-old male with history of hypertension and recent diagnosis of UC who was doing well on mesalamine developed a flare with acute onset diarrhea, abdominal pain, and rectal bleeding. Stool tests were negative for C difficile and common bacterial and viral pathogens. Fecal calprotectin was >2000 μg/mg, and CT abdomen/pelvis was notable for thickened colon walls. Colonoscopy showed moderate inflammation with aphthous ulcerations throughout the colon with sparing of the cecum. Patient was started on oral steroids and transitioned to adalimumab. He continued to have weight loss and diarrhea and was switched to vedolizumab after two months. Due to continued symptoms, repeat colonoscopy 6 months later showed severe inflammation with confluent ulcerations in continuous and circumferential pattern from rectum to transverse colon (Figure 1). Laboratory workup was notable for anemia (hgb 9.0 g/dL), hypoalbuminemia (2.9 g/dL) and high C-reactive protein (3.22 mg/dL). Patient was admitted for IV steroids. Infliximab was started on day 5 due to no improvement in symptoms. At this time biopsies obtained during colonoscopy were reported to be positive for EBV-encoded small RNA by in-situ hybridization (Figure 2). EBV was also detected in whole blood by PCR. IV gancyclovir was started. After 7 days of treatment with gancyclovir, repeat flexible sigmoidoscopy showed no significant improvement. Immunostains for EBV, CMV, and HSV were negative. EBV PCR declined (60,000 to 30,000 IU/ml). A subtotal abdominal colectomy with end ileostomy and rectal stump was eventually performed without any complications. Patient gained weight and did well post operatively. DISCUSSION: EBV colitis with fulminant UC is rare. The clinical implication of EBV colitis and treatment benefits are unclear. In addition, there is lack of a standard therapy for EBV infection with case reports showing improvement with gancyclovir. Our case of true EBV colitis with fulminant UC illustrates the importance of considering a superimposed infection in patients with IBD refractory to steroids and immunosuppressive therapy early in the course of the disease to prevent progression.