S5089 Infectious Implications: EBV Positive Colon Tissue in Refractory and Indeterminant Colitis

Introduction: Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the gastrointestinal tract that is frequently treated with immunosuppressants including biologic therapies. These immunosuppressant therapies and the disease process itself are associated with increased risk of opportunistic infections. One such infection, Epstein-Barr virus (EBV), is known for its potential to develop into EBV-associated lymphoproliferative disorder among immunosuppressed IBD patients. Additionally, EBV is gaining more attention for its possible role in IBD progression and refractoriness to treatment. This case reviews a patient with indeterminant colitis refractory to intravenous (IV) steroids and Infliximab that ultimately underwent a colectomy with multiple colon tissue samples staining positive for EBV. Case Description/Methods: A 68-year-old man diagnosed with IBD 2 years prior was originally treated for ulcerative colitis with mesalamine and steroids. He was admitted for an IBD flare with associated diarrhea, hematochezia, abdominal pain, and 25 pounds of weight loss over 2 months. A trial of IV steroids provided no symptomatic improvement and Infliximab was subsequently started. Days later, a colonoscopy revealed severe distal colitis with distinct areas of ulcerations in the proximal colon with pathology most consistent with indeterminate colitis. After no change in symptoms, the patient opted for surgical intervention with subtotal colectomy. Interestingly, the surgical samples from the descending colon and cecum were found to have many activated lymphocytes leading to further testing revealing EBV positive samples with EBER staining clusters and up to 50 inflammatory cells per high-power field. Discussion: This presentation of EBV positive colonic tissue samples from a refractory IBD patient raises the question of what role this virus plays in disease progression and refractoriness. Prior research on patients with IBD has demonstrated EBV staining in colon tissue was positively correlated with disease severity and more common in refractory cases. Further questions remain including whether EBV is driving the worsening of IBD severity and refractoriness or is it a bystander and when should EBV treatment be considered. Future research can aim to answer these questions.