Severe colitis associated with rotavirus in a child with CUC

Abstract

CASE PRESENTATION: A 12-year-old boy diagnosed with ulcerative colitis (UC) hadbeen previously managed successfully with anti-TNF agents being refractory to 5-ASA therapy. Low TPMT activity precluded initial thiopurine therapy. He remainedin clinical remission for 12 months on infliximab infusion every 8 weeks. Progressiveloss of response resulted in shortening of infusion interval to q6 weeks. Abruptly, his symptoms progressed to 10-15 bloody stools/day with urgency and abdominalcramping. The patient was hospitalized and infectious pathogens including C.difficile and CMV were excluded. Upon hospitalization, parenteral corticosteroidsand very low dose thiopurines were started. The disease remained refractory to 7days IV corticosteroids and both calcineurin inhibitor therapy and surgery wereconsidered. Pathology obtained from a limited flexible sigmoidoscopy revealedneutrophils in the lamina propria with cryptitis and crypt abscess suggesting infectious-type colitis superimposed on chronic colitis figure1. At that point the decisionwas made to repeat his stool studies including fecal rotavirus Antigen (Ag).Rotavirus Ag was positive and patient was treated with 3 days course of oralimmunoglobulins 1 g/kg. Patient's symptoms improved rapidly over 24hr allowingtaper of corticosteroids and eventual discharge from the hospital.DISCUSSION: The role of virus in CUC exacerbation is unclear. Rotavirus is not typicallyscreened in our patient population. Oral immunoglobulin rapidly led toimprovement and discharge from the inpatient setting. Conclusion: Further prospective study of viral pathogens in refractory colitis isindicated.