Cytomegalovirus infection in a patient with Crohn's ileocolitis.

Cytomegaloviral enterocolitis is an uncommon infection that can complicate inflammatory bowel disease. A case of a patient with a three-year history of Crohn's disease is reported. He had been in a stable condition on mesalamine 4 g/day and methylprednisolone 10 mg/day for three years until four weeks before admission. The patient was admitted with complaints of fever, abdominal pain and watery diarrhea. A diagnosis of an exacerbation of Crohn's disease was established. The radiological examination revealed narrowing of the terminal ileum. Multiple fistulas and abscess-like images were observed. The patient then underwent ileocolic resection and ileostomy. The histopathological examination revealed Crohn's ileocolitis with superimposed cytomegalovirus infection. In patients with rapidly deteriorating inflammatory bowel disease, cytomegalovirus infection should be kept in mind as one of the differential diagnoses.     

Pancreatitis coincident with Crohn's ileocolitis

A young woman who developed acute pancreatitis coincident with Crohn's disease is presented. The pancreatitis was documented by pancreatic hyperamylasemia, elevated urine amylase activity, abdominal sonogram, computed tomography, and laparotomy. A cause-and-effect relationship has not been established, however; no etiology other than the Crohn's disease, which was confined to the ileum and colon, could be identified. Surgical removal of the severely involved ileum led to the resolutionof the pancreatitis. A possible relationship between acute pancreatitis and Crohn's disease is proposed, although potential pathophysiologic mechanisms are unknown. The diagnosis of pancreatic involvement in such cases may make an important contribution to therapy.     

A case of cytomegalovirus colitis with endoscopic finding resembling Crohn's disease

Cytomegalovirus (CMV) colitis is common among immunocompromised patients, and often diagnosed by pathologic confirmation because it is associated with a diverse spectrum of clinical and endoscopic features. However, Crohn's disease has no definitive diagnostic criteria, but longitudinal ulcers and cobble stone appearance are accepted as typical endoscopic features of Crohn's disease. An 83 year-old male with a history of radiotherapy for hypopharyngeal cancer visited our hospital with a complaint of melena for 1 week. His colonoscopic exam showed multiple longitudinal ulcers along the entire colon. Most of the ulcers were longer than 4 cm, these endoscopic findings were suspected as typical endoscopic features of Crohn's disease. Pathologic reports revealed multiple inclusion bodies with CMV on immunohistochemistry. He was finally diagnosed as having CMV colitis, and received a 3 week-course of intravenous ganciclovir. A colonoscopic follow-up showed complete healing of the multiple longitudinal ulcers, and he is doing well now without further treatment.     

Differentiating Crohn's disease from intestinal tuberculosis

Differentiating Crohn's disease(CD) and intestinal tuberculosis(ITB) has remained a dilemma for most of the clinicians in the developing world, which are endemic for ITB, and where the disease burden of inflammatory bowel disease is on the rise. Although, there are certain clinical(diarrhea/hematochezia/perianal disease common in CD; fever/night sweats common in ITB), endoscopic(longitudinal/aphthous ulcers common in CD; transverse ulcers/patulous ileocaecal valve common in ITB), histologic(caseating/confluent/large granuloma common in ITB; microgranuloma common in CD), microbiologic(positive stain/culture for acid fast-bacillus in ITB), radiologic(long segment involvement/comb sign/skip lesions common in CD; necrotic lymph node/contiguous ileocaecal involvement common in ITB), and serologic differences between CD and ITB, the only exclusive features are caseation necrosis on biopsy, positive smear for acid-fast bacillus(AFB) and/or AFB culture, and necrotic lymph node on cross-sectional imaging in ITB. However,these exclusive features are limited by poor sensitivity, and this has led to the development of multiple multi-parametric predictive models. These models are also limited by complex formulae, small sample size and lack of validation across other populations. Several new parameters have come up including the latest Bayesian meta-analysis, enumeration of peripheral blood T-regulatory cells, and updated computed tomography based predictive score. However, therapeutic anti-tubercular therapy(ATT) trial, and subsequent clinical and endoscopic response to ATT is still required in a significant proportion of patients to establish the diagnosis. Therapeutic ATT trial is associated with a delay in the diagnosis of CD, and there is a need for better modalities for improved differentiation and reduction in the need for ATT trial.     

Spontaneous portal venous gas in a patient with Crohn's ileocolitis

In a 70-year-old man with Crohn's ileocolitis who presented with a sudden fever, ultrasound and computed tomographic (CT) examinations showed hepatic portal venous gas (HPVG). Abdominal plain film was normal. The course was benign with medical management. The authors review previous cases of portal vein gas in intestinal inflammatory diseases.     

肠结核与克罗恩病的临床鉴别及肠黏膜结核分枝杆菌聚合酶链反应检测的意义

目的总结肠结核与克罗恩病临床症状、内镜、病理表现的差异及肠黏膜组织结核分枝杆菌聚合酶链反应（polymerasechain reaction for Mycobacterium tuberculosis,TB-PCR）对二者鉴别诊断的意义。方法回顾分析1994年1月-2006年2月于我院确诊的42例肠结核和60例克罗恩病病例,记录患者的临床、内镜、病理表现特点及肠黏膜TB-PCR检测结果。结果克罗恩病患者临床表现为消化道出血者占56.9%（33/58）,较肠结核（16.1%,5/31）多见（P〈0.001）;29.3%克罗恩病患者有肠外表现（口腔溃疡、皮疹、关节痛、肛周病变）,而肠结核患者未见;内镜下克罗恩病表现为纵行/裂隙样溃疡（44.9%,22/49）、卵石征（28.6%,14/49）、节段性病变（51.0%,25/49）多于肠结核（7.7%、3.9%、0）（P值分别为0.001、0.011、0.000）;克罗恩病患者肠黏膜组织病理表现为淋巴细胞聚集占34%（18/53）,小血管炎占26.4%（14/53）,明显较肠结核多见（0%、3.8%）（P值分别为0.001、0.016）。82.4%（14/17）的肠结核患者试验性抗结核1-2周症状改善,而5例克罗恩病患者试验性抗结核治疗4-8周均无效。肠黏膜组织TB-PCR检测阳性率肠结核组为11.5%（3/26）;与CD组（14.3%,3/21）比较无显著差异（P〉0.5）。结论肠结核与克罗恩病鉴别需结合临床表现、内镜、影像学表现综合判断;肠黏膜TB-PCR对肠结核与CD鉴别诊断的意义有限;试验性抗结核治疗及内镜随访仍是鉴别肠结核与克罗恩病的有效方法。     

克罗恩病与肠结核的临床分析与比较

目的对克罗恩病(CD)与肠结核(IT)进行临床分析和比较,找出对鉴别诊断有帮助的要点。方法回顾性分析我院1983年~2004年间住院的62例CD患者和21例IT患者的临床资料。结果CD男性多见。临床表现、各种并发症的出现、实验室检查、腹部B超/CT以及消化道造影均对鉴别诊断帮助不大,CD的肠黏膜活检诊断率低。CD与IT的常见部位都是回肠及回盲部,但CD可累及直肠,吻合口病变为77.4%。CD纵行溃疡仅占13.6%,而环形溃疡却占26.7%,回盲瓣受累22.2%,IT瘘管形成并不罕见(14.3%)。CD肠系膜淋巴结最大直径为(10±3)mm,均无上皮样肉芽肿,而IT肠系膜淋巴结最大直径为(18±5)mm,P<0.01,均有上皮样肉芽肿,41.2%有干酪样坏死。CD裂隙溃疡多于IT(P<0.01)。CD中全层炎、淋巴组织增生、黏膜下层水肿均比IT多(P<0.05)。结论CD与IT的鉴别需要多方面综合判断,手术标本的病理对鉴别有重要意义。     

Pathology of intestinal tuberculosis and its distinction from Crohn's disease

Intestinal lesions of 212 cases presenting with symptoms of intestinal obstruction were studied. Of these, 159 cases were diagnosed as tuberculosis and 10 as Crohn's disease. Forty-three cases could not be classified into any of these entities and are excluded from this account. The amount of chemotherapeutic drugs received by each patient preoperatively was recorded. Cases proved as tuberculosis at the first operation were put on antituberculosis chemotherapy. Thirteen of these cases were operated on a second time, and tissue reactions under the influence of chemotherapy were studied. Fresh diseased tissue was studied for acid-fast organisms by culture and animal inoculation.Morphological features of the tuberculosis group are described in detail. Although the cases were broadly classified into the ulcerative and ulcerohypertrophic varieties, a distinction was not always sharp and the two types of lesions were at times found to coexist. The macroscopic features presented a very wide range, and at times distinction from Crohn's disease, especially in the ulcerohypertrophic variety, was difficult. Microscopically, however, they could be distinguished without much difficulty. Caseation, although a characteristic feature of tuberculous granulomas may, albeit rarely, be absent. Granulomas which are characteristically confluent may be present only in the mesenteric lymph nodes. Acid-fast organisms are not grown consistently from diseased tissues; where grown, they are of human type. Reparative changes during chemotherapy are described in detail; these follow a non-specific pattern.In the group of Crohn's disease, transmural cracks and fissures were consistently observed in all cases. Distinguishing features between the two diseases are discussed in detail.     

Emergency colectomy for cytomegalovirus ileocolitis in patients with the acquired immune deficiency syndrome

The charts of all patients with the acquired immune deficiency syndrome (AIDS) who underwent emergency intra-abdominal surgery between January 1981 and July 1987 were reviewed. Eleven AIDS patients underwent 13 emergency laparotomies. Seven of these patients (64 percent) had cytomegalovirus (CMV) ileocolitis as the pathologic process requiring emergent surgical intervention. Four patients had hemorrhagic CMV proctocolitis and three had perforations of CMV ulcers of the ileum or rectosigmoid. The operations performed included three subtotal colectomies, two segmental resections, and two diverting stomas. The postoperative mortality rate in the CMV group was 28 percent at one day, 71 percent at one month, and 86 percent at six months. Furthermore, CMV ileocolonic pathology was directly responsible for 70 percent of the deaths in AIDS patients who underwent emergent exploratory laparotomy. Read at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988. This paper received the Chicago Society of Colon and Rectal Surgeons Award.     

Disseminated cytomegalovirus infection in Crohn's disease following anti-tumour necrosis factor therapy

This case report describes a 63-year-old woman with a 15-year history of Crohn's disease. After a severe relapse with colitis she was treated with immunosuppressive agents, including an increased dosage of corticosteroids, azathioprine and a single dose of infliximab (anti-tumour necrosis factor-alpha). This led to a brief improvement, which was followed by worsening diarrhoea, fever and skin lesions. Biopsies from upper and lower endoscopies and from an ulcerative skin lesion revealed cytomegalovirus vasculitis in all the tissues removed. The patient improved slowly by withdrawal of the immunosuppressives and with anti-viral therapy. Whenever patients with inflammatory bowel disease deteriorate rapidly, cytomegalovirus infection should be ruled out before the immunosuppressive therapy is fortified.     

Prevalence of cytomegalovirus infection in severe refractory ulcerative and Crohn's colitis

OBJECTIVES: Cytomegalovirus infection has been reported as a cause of refractory inflammatory bowel disease, but no data are available on its prevalence in severe colitis. The aim of this study was to evaluate the prevalence and outcome of cytomegalovirus infection in a consecutive series of patients with severe steroid refractory colitis admitted to our department from 1997 to 1999. METHODS: Among 62 patients with severe colitis, 55 with ulcerative colitis and seven with Crohn's disease, 19 (30%) were resistant to intravenous steroids and bowel rest. In all of them, rectal biopsies were examined for cytomegalovirus (the flexible proctoscopy being performed without air insufflation and limited to the first 10 cm). Buffy coat preparation on leukocytes was also performed to detect systemic infection. If cytomegalovirus was not detected, cyclosporine was started. RESULTS: In seven (five with ulcerative colitis and two with Crohn's disease) out of 19 (36%) patients with refractory disease, cytomegalovirus was diagnosed in the rectal specimens as well as by buffy coat preparation. Five patients went into remission after antiviral treatment (three with ganciclovir and two with foscarnet). One patient did not respond and was operated on. In one patient, cytomegalovirus was found in the surgical specimen. CONCLUSIONS: Cytomegalovirus infection is a frequent cause of severe refractory colitis. Rectal biopsy should always be performed in severe steroid-resistant colitis.