P1334 Acute Severe Ulcerative Colitis: When Epstein-Barr Virus Joins Forces with Clostridioides difficile
Authors: Côrte-Real F , Rego A C , Silva A R , Flor de Lima M , Almeida M , Pereira J R , Paz N , Carneiro V , Nunes N , Duarte M A 
Published: January 2025

Abstract

Background
We report the case of a 47-year-old female presenting with bloody, mucous diarrhea (10 bowel movements per day), generalized colicky abdominal pain persisting for two months, and significant weight loss of 5 kg within one month. Upon admission, the patient was normotensive, tachycardic (heart rate: 109 bpm), and febrile (temperature: 38.7ºC). Laboratory tests revealed hemoglobin of 12.4 g/dL, leukocyte count of 134,000/μL, platelet count of 537,000/μL, hypoalbuminemia (2.2 g/dL), and elevated C-reactive protein (CRP, 20.4 mg/dL), without evidence of hyperlactatemia.

Methods
Abdominal computed tomography (CT) demonstrated colonic dilation, primarily affecting the transverse colon, along with thickening of the descending colon wall. Rectosigmoidoscopy showed edematous mucosa with spontaneous bleeding and multiple deep ulcerations.
The diagnosis of Severe Acute Ulcerative Colitis was established based on clinical, endoscopic, and radiological findings (Truelove & Witts score: severe; Mayo endoscopic subscore: 3), and intravenous corticosteroid therapy was initiated.
Tests for Clostridioides difficile toxin A and B, as well as antigen, were positive, prompting treatment with vancomycin, as fidaxomicin was unavailable. Rectosigmoidoscopic biopsies confirmed active Clcerative Colitis and revealed the presence of Epstein-Barr virus (EBV) through in situ hybridization, consistent with EBV infection. Cytomegalovirus (CMV) was excluded in the biopsies, and ganciclovir therapy was started.

Results
On day three of corticosteroid therapy, due to a lack of response per the Oxford score, infliximab was initiated. Despite two doses, the patient persisted with seven bloody bowel movements daily, tachycardia, and hypotension, alongside transverse colon dilation (7.6 cm). This clinical course necessitated an emergency laparoscopic total proctocolectomy with Brooke-type ileostomy.
Histopathological examination of the surgical specimen revealed microscopic changes characteristic of ulcerative colitis, predominantly affecting the transverse, descending, sigmoid colon, and rectum, with lesser involvement of the cecum and ascending colon. At the twelve-month follow-up, the patient remained asymptomatic.

Conclusion
EBV colitis is rare in patients not undergoing immunosuppressive therapy, as demonstrated in this case. While CMV testing in ulcerative colitis patients is widely recognized as essential, screening for EBV in intestinal mucosa is not routinely performed.This case underscores the importance of investigating coinfections, including CMV, C. difficile, and EBV, in patients experiencing acute exacerbations of ulcerative colitis. EBV infection is associated with symptom exacerbation, poorer prognosis, and an increased likelihood of colectomy.

References
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2 -Zhang H, Zhao S, Cao Z. Impact of Epstein–Barr virus infection in patients with inflammatory bowel disease. Front Immunol. 2022;13(October):1–15.
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