Diarrhea occurred after eating greasy food, symptomatic treatment did not improve, the cause was actually this disease!

It is only for medical professionals to read and refer to.
This issue of "Intestinal Governance" will share with you a case of ulcerative colitis combined with opportunistic infection: How should such patients be evaluated and treated? Let's learn together! Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD).
The treatment of UC often requires the application of hormones or immunosuppressive agents.
In addition to the intestinal mucosal barrier damage and malnutrition caused by the disease itself, giant cells are prone to appear Virus (CMV) and Epstein-Barr virus (EBV) infection
.

Now I would like to share with you a case of UC combined with opportunistic infection.
The analysis of the treatment plan is shown below
.

Summary of medical history The patient developed diarrhea after eating greasy food more than 1 month before admission, with nausea, vomiting, no abdominal pain, and no stopping of bowel movements, 4-5 times a day.
The patient went to a local hospital and considered: "dysentery".
Anti-infection, fluid rehydration and other treatments were given, and the patient's symptoms did not alleviate
.

Five days before admission, the patient developed pain in the lower abdomen, accompanied by mucus, pus, and blood in the stool.
He had stool about 3 times a day, accompanied by nausea, vomiting, fatigue, and anorexia.
The patient presented to our hospital
.

Colonoscopy was performed.
The result: colorectal mucosa with high congestion and edema, mucosal erosion and shallow ulcer, diagnosis: ulcerative colitis
.

The patient has lost 20 kg in weight since the onset of this disease
.

After admission, the intestinal tissue was tested positive for CMV nucleic acid, and the intestinal tissue was positive for EBV nucleic acid, and antiviral drugs were given
.

2.
Analysis and discussion 2.
1 Analysis of the reasons for UC patients with opportunistic infections IBD patients are high-risk groups of opportunistic infections
.

First of all, the disease itself can cause the patient's nutritional status to decline; secondly, the application of glucocorticoids, immunosuppressants and biological agents can severely suppress the patient's immunity [1]
.

Therefore, the incidence of opportunistic infections in IBD patients has increased significantly
.

The patient had a clear diagnosis of UC, diarrhea for more than 1 month, intermittent abdominal pain with mucus pus and blood in the stool for more than half a month, hemoglobin 96g/L, albumin 22g/L, anemia, malnutrition, etc.
, which met the causes of opportunistic infections mentioned above
.

2.
2 Clinical features of UC combined with CMV and EBV infection Compared with UC patients without CMV and EBV infection, UC patients with CMV and EBV infection are more common in abdominal pain, weight loss, higher red blood cell sedimentation rate, C-reactive protein level, and hemoglobin The blood albumin level is low, deep and large ulcers are more common under endoscopy, the activity grade is mostly level III, and glucocorticoid dependence is more common [2]
.

The patient's lower abdomen pain, weight loss of 20 kg since the onset, hemoglobin 96g/L, albumin 22g/L, basically in line with the clinical characteristics of CMV and EBV infection
.

2.
3 The impact of CMV and EBV on the condition of UC has shown that the positive rate of CMV is 10% in active UC patients, 21%-34% in acute severe UC, and 33%-36% in hormone refractory cases [3]
.

EBV infection is associated with aggravation of UC and may induce EBV-related lymphoproliferative diseases
.

The condition of UC patients with CMV and EBV infection is more serious than that of patients with negative CMV and EBV
.

Foreign studies also found [4] that the EBV DNA of the intestinal mucosa of patients with acute exacerbation of IBD is higher than that of patients with IBD in remission, suggesting that EBV may have a potential effect on aggravating the condition of IBD
.

3.
Analysis of treatment plan for UC combined with CMV and EBV infection 3.
1 Do UC patients with CMV and EBV need antiviral therapy? In clinical practice, only a small part of CMV infection can cause disease.
Therefore, except for patients with IBD who are resistant to glucocorticoids, it is not recommended to screen for CMV before starting immunomodulator therapy
.

If CMV infection is found during treatment with immunomodulators, subclinical or mild infections can be left untreated, which is self-limiting
.

Severe systemic CMV infection is rare, but the prognosis is usually poor.
Once it occurs, immunomodulator therapy must be stopped and antiviral therapy must be started
.

EBV infection is often self-limited in people with normal immunity, but it can cause critical illness in immunosuppressed patients
.

Therefore, the ECCO consensus recommends that EBV should be tested before the start of immunomodulator therapy
.

Severe primary EBV infection occurs during immunomodulator treatment, and antiviral therapy can be considered and the immunomodulator treatment terminated
.

3.
2 Selection of antiviral drugs The main treatment drugs for CMV are ganciclovir and foscarnet sodium
.

The ganciclovir usage is 5 mg/kg (2 times/d) intravenously, and the course of treatment is generally no less than 3 weeks
.

Valganciclovir is a prodrug of ganciclovir with good oral bioavailability.
After absorption, it is phosphorylated into ganciclovir triphosphate.
Its curative effect is equivalent to that of ganciclovir.
The conventional dose is 900mg ( 2 times/d), can be used as oral maintenance treatment
.

The efficacy of foscarnet sodium is equivalent to that of ganciclovir.
The usage is 180 mg·kg-1·d-1 intravenously, administered in 2-3 times, and the course of treatment is generally no less than 3 weeks
.

There are many EBV-positive cells in IBD intestinal mucosal biopsies, but there are no systemic symptoms such as fever.
Considering the EBV opportunistic infection that may be localized in the intestine [5], it is not clear whether antiviral therapy is needed
.

However, if more EBV-positive cells are detected in the intestinal mucosa of IBD patients, it is recommended to avoid using immunosuppressive drugs as much as possible
.

In summary, the intestinal EBV infectious disease still lacks a standardized diagnosis and treatment plan, and further clinical and pathological studies are needed
.

For the treatment of CMV, the guidelines clearly recommend ganciclovir and foscarnet sodium; for the treatment of EBV, the guidelines do not give recommendations
.

Therefore, consider patients with CMV and EBV infection
.

The patient weighed 42 kg.
According to the drug instructions, the dosage was 105 mg/time, 2 times/d, and the course of treatment was not less than 3 weeks
.

In clinical treatment, the patient was given 100mg of ganciclovir for injection + 100mL of 0.
9% sodium chloride injection, q12h, ivgtt, for 17 days, after which the histological test of CMV nucleic acid turned negative, and the EBV nucleic acid test was still positive
.

Combined with the patient's clinical manifestations, antiviral therapy is effective
.

Fourth, follow-up monitoring During the use of ganciclovir for injection, it is necessary to monitor the adverse reactions, the most common ones are the blood and lymphatic system, including anemia, hemoglobin reduction anemia, leukopenia, bone marrow suppression, and various types of blood cell reduction.
Thrombocytopenia and so on
.

In patients with UC, anemia is the most common extraintestinal manifestation.
The combined use of ganciclovir should regularly monitor blood routines and evaluate the patient's hemoglobin level
.

References: [1] Kim JJ, Simpson N, Klipfel N, et al.
Cytomegalovirus infection in patients with active inflammatory bowel disease[J].
Dig Dis Sci,2010, 55: 1059-1065.
[2] Liu Jinglong, Xi Jingjing, Optimized treatment plan for refractory ulcerative colitis caused by cytomegalovirus infection[J].
Chinese Medicines and Clinics, 2019, 19(3): 477-479.
[3] Huang Ying, Yang Xuesong, Li Jun, Ulcerative Colon Clinical characteristics of patients with inflammatory bowel disease combined with cytomegalovirus and Epstein-Barr virus infection[J].
International Journal of Virology, 2019, 26(3): 197-201.
[4] Qinghua Sun, Jinping Zhang, Dongying Li, Jiansheng Li, Chance of Inflammatory Bowel Disease Diagnosis and treatment strategies for sexual infections[J].
Journal of Gastroenterology and Hepatology, 2015, 24(12):1522-1526.
[5] Inflammatory Bowel Disease Group, Chinese Society of Gastroenterology, Chinese Medical Association Consensus opinions of experts on combined opportunistic infections[J].
2017, 37(4): 217-226.
Introduction of experts Prof.
Xiaocang Cao, chief physician of the Department of Gastroenterology, Tianjin Medical University General Hospital, professor, master tutor of Tianjin Medical University, Peking Union Medical College ∙ Doctor of Medicine, Tsinghua University, postdoctoral fellow at Texas State University School of Medicine, and postdoctoral visiting scholar at the University of Lille School of Medicine in France
.

Member of the Digestive Endoscopy Committee of the Inflammatory Bowel Disease Group of the Chinese Medical Association Gastroenterology Branch, Deputy Chairman of the Youth Committee of the Behavioral Medicine Branch of the Chinese Medical Association, Member of the Clinical Epidemiology Cooperation Group of the Digestive Branch of the Chinese Medical Association, Digestive Diseases of the Chinese Medical Equipment Association Member of the Inflammatory Bowel Disease Group of the Academic Subcommittee, Member of the Inflammatory Bowel Disease Professional Committee of the Anorectal Physician Branch of the Chinese Medical Doctor Association, Member of the Inflammatory Bowel Disease Expert Committee of the Digestive Endoscopy Professional Committee of the Chinese Integrative Medicine Association, Beijing Member of the Inflammatory Bowel Disease Expert Committee of the Medical Award Foundation, Member of the Intestinal Microecology Professional Committee of the Wu Jieping Medical Foundation Inflammatory Bowel Disease Alliance, Member of the Standing Committee of the Stem Cell Engineering Technology Branch of the Chinese Society of Biomedical Engineering, Tianjin Medical Association of Digestion Inflammation The research direction of the Deputy Chairman of the Gastroenterology Group: Inflammatory bowel disease and digestive tract immune disease, autoimmune disease biological therapy and cell therapy, especially dedicated to the clinical application of mesenchymal stem cell transplantation
.

The research results have won awards from international conferences such as the American Digestive Academy Annual Meeting and the European Union Digestive Academy Annual Meeting, and dozens of papers have been published in SCI journals and Chinese journals
.

Xie Dong is a clinical pharmacist in the General Hospital of Tianjin Medical University, a clinical pharmacist in the Department of Gastroenterology, a national clinical pharmacist training base, and an MTM pharmacist certified by the American Pharmacists Association (APhA)
.

Wang Ping, Clinical Pharmacist, Beichen Hospital, Tianjin