Cytomegalovirus in inflammatory bowel disease: a clinical approach

Prevalence of opportunistic infections in Syrian inflammatory bowel disease patients on biologic therapy: a multi-center retrospective cross-sectional study

BACKGROUND

Hepatitis B, hepatitis C, cytomegalovirus (CMV), and tuberculosis (TB) pose significant risks to patients with inflammatory bowel disease (IBD) receiving biological therapy. However, data on the prevalence of these infections in Syria are scarce.

METHODS

We conducted a retrospective chart review of IBD patients receiving biologic therapy at Damascus Hospital and Ibn Al-Nafees Hospital, two major public institutions in Syria, between January 2021 and November 2024. A minimum sample size of 130 was estimated; however, all available records were reviewed.

RESULTS

Among 185 IBD patients (104 from Damascus and 81 from Ibn Al-Nafees), 51.4% had ulcerative colitis and 47.6% had Crohn's disease. The smoking prevalence was 9.2%, which was higher in Crohn's disease (5.9%) than in ulcerative colitis (3.2%). TST performed in 61.1% of patients, with 4.3% positivity, and interferon-gamma release assay (IGRA) in 8.7% (1.1% positive). Hepatitis B surface antigen (HBsAg) and anti-HBc antibodies were found in 2.7% and 5.4% of the patients, respectively, while hepatitis C seroprevalence was low (0.5%). CMV seropositivity was high in Damascus (50.8%), with two cases (1.1%) of CMV colitis. Biologic therapies included infliximab (42.7%), ustekinumab (24.3%), golimumab (10.8%), and adalimumab (6.5%). Data gaps, particularly in viral serology and TB screening, are notable.

CONCLUSION

This study identifies deficiencies in TB/hepatitis B screening (notably anti-HBs Ab) and elevated CMV seroprevalence among Syrian IBD patients receiving biologics, extending to immunosuppressed cohorts (rheumatology, dermatology, oncology). Insufficient screening heightens occult infection/reactivation risks, necessitating standardized pretreatment protocols to reduce morbidity in high-risk populations.

CLINICAL TRIAL NUMBER

Not applicable.

Cytomegalovirus in Ulcerative Colitis: An Unwanted "Guest"

The role of cytomegalovirus (CMV) in the flare-up of ulcerative colitis (UC) is not clearly understood. CMV can cause similar symptoms in different clinical contexts, which may be attributed to the natural evolution of the viral infection, the patient's immune status, or its association with inflammatory bowel disease (IBD). This study aims to delineate the diverse manifestations of CMV-related lesions from clinical, endoscopic, and histopathological perspectives, alongside a brief narrative review of the literature. In managing IBD patients, it is crucial to be vigilant for signs of CMV reactivation, especially before the initiation of more intensive therapies.

Cytomegalovirus Infection: An Underrated Target in Inflammatory Bowel Disease Treatment

CMV infection is still a matter of concern in IBD patients, especially regarding the disease's relapse management. Why IBD patients, particularly those affected by ulcerative colitis, are more susceptible to CMV reactivation is not totally explained, although a weakened immune system could be the reason. Various techniques, ranging from serology to histology, can be employed to detect intestinal CMV infection; however, there is currently disagreement in the literature regarding the most effective diagnostic test. Furthermore, CMV involvement in steroid resistance has been broadly discussed, but whether CMV infection is a cause or consequence of the disease severity and, consequently, steroid refractoriness is still debated. Its potential contribution to the lack of response to advanced therapy and small molecules must be more valued and wholly explored. In this review, we look at the actual literature on CMV in IBD patients, and we suggest a pragmatic algorithm for clinical practice management of CMV infection.

Malnutrition Defined by the Global Leadership Initiative on Malnutrition (GLIM) Criteria in Hospitalized Patients with Ulcerative Colitis and Its Association with Clinical Outcomes

(1) Background: The Global Leadership Initiative on Malnutrition (GLIM) was published in 2019, and its application has been explored in several diseases. However, the data on malnutrition based on the GLIM in ulcerative colitis (UC) patients are sparse. (2) Methods: This single-center, retrospective cohort study included 605 hospitalized UC patients. Demographics and clinical data were collected from electronic medical records. Nutritional Risk Screening 2002 (NRS 2002) was used as a screening tool, and malnutrition was diagnosed according to the GLIM criteria. The skeletal muscle area of the third lumber cross-section in abdominal computed tomography was used to evaluate muscle mass within one week before or after admission. (3) Results: The prevalence of malnutrition was 64.1% in this cohort, and the prevalences were 34.2, 57.7, and 86.7% in UC patients with mild, moderate, and severe disease activity, respectively. Malnourished patients tended to need surgical treatment (p = 0.080) and had a 2.4 times greater risk of opportunistic infection. The multivariate logistic regression analysis showed that UC patients with malnutrition had a 1.7-fold increased risk of readmission. (4) Conclusions: Nutritional problems deserve more attention in hospitalized UC patients. Malnutrition identified through the GLIM criteria was associated with opportunistic infection, tended to be associated with surgical treatment, and showed a prognosis value for readmission.

Hemophagocytic Lymphohistiocytosis Associated With Cytomegalovirus Infection: 5 Cases and a Systematic Review of the Literature

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder characterized by an uncontrolled, persistent, hyperimmune response. It can be triggered by an infectious, neoplastic, or autoimmune event. The involvement of cytomegalovirus (CMV) in the onset of HLH is subject to debate, and the epidemiology of CMV-associated HLH (HLH-CMV) remains poorly characterized. We identified 5 cases of HLH-CMV in our hospital, systematically searched the PubMed database for publications on HLH-CMV, and reviewed 57 publications with a total of 67 cases of HLH-CMV. Only 48 patients (71.6%) were immunodeficient, suggesting that HLH-CMV can occur in immunocompetent patients. The major cause of underlying immunodepression (51%) was inflammatory bowel disease (mainly treated with azathioprine). CMV infection was nearly always symptomatic, and lung involvement was frequent (31 cases). Fifty-five patients recovered. Nineteen patients were treated for CMV infection only and had a good outcome, suggesting that antiviral drugs might be the cornerstone of HLH-CMV treatment.