P1255 - No Stone Left Unturned: Rapid Induction of Remission With Upadacitinib Followed by Cytomegalovirus (CMV)-Colitis in a Hospitalized Patient With Crohn’s Disease (CD)
Reid Herran, MD1, Samuel Wilcox, MD1, Gal Hodish, MPH1, Asma Nusrat, MD1, Jiaqi Shi, MD, PhD1, Abhishek Satishchandran, MD, PhD2, Rutwik Pradeep. Sharma, MD3, Shrinivas Bishu, MD1, Syed A. Hassan, MBBS1, John Byrn, MD1, Haley Mertens, MD4, Anastasia Wasylyshyn, MD1, Peter D. R.. Higgins, MD, PhD, MSc1, Jeffrey Berinstein, MD, MS1 1University of Michigan, Ann Arbor, MI; 2University of Michigan, Lansing, MI; 3University of Michigan-Sparrow Hospital, Lansing, MI; 4University of Michigan, Chelsea, MI Introduction: Patients with CD who develop severe symptoms often require hospitalization for rapid induction of remission to improve symptoms and prevent progression of complications.
Case Description/
Methods: A 60-year-old woman with ulcerative proctitis (diagnosis changed to CD due to penetrating perianal disease) on mesalamine, hydrocortisone enemas, and prednisone 20mg (taper) presented with severe rectal pain and bloody diarrhea. Her hemoglobin (Hgb) was 10 g/dL, C-reactive protein (CRP) 27 mg/dL, albumin 2.6 mg/dL, and fecal calprotectin 3173 mg/kg. Serum CMV PCR was positive with viral load < 50 IU/mL. MRI pelvis showed an intersphincteric perianal fistula with a 3.3 cm horseshoe abscess and active proctocolitis. She was started on IV methylprednisolone. Flexible sigmoidoscopy revealed large, deep ulcers in the rectum and sigmoid (extent reached, Figure 1); histology showed chronic active colitis with negative CMV immunostain. Given severe inflammation and low albumin, high-intensity, off-label upadacitinib (30 mg BID) was initiated.
After 8 days of upadacitinib, her symptoms and CRP normalized. Despite improved stool frequency, she developed new onset hematochezia and her Hgb dropped to 5.8 g/dL. Colonoscopy showed mucosal healing and improved fecal calprotectin (285 mg/kg), with histology revealing regenerative changes and quiescent colitis (Figure 1). Upadacitinib was decreased to 45 mg daily, and she transitioned to oral prednisone. Unfortunately, less than 2 weeks following the improved colonoscopy, she developed recurrent abdominal pain, worsening bloody stools, and rising CRP (Figure 2). She was deemed medically refractory and underwent total colectomy. Surgical pathology revealed CMV colitis, without any active Crohn’s disease. CMV PCR viral load was 2236 IU/mL. CMV infection resolved with ganciclovir. Discussion: While this patient had a rapid initial response to off-label, high-intensity upadacitinib, she subsequently demonstrated clinical deterioration ultimately undergoing colectomy for suspected refractory CD. Surgical pathology unexpectedly revealed quiescent CD with CMV colitis despite no initial endoscopic evidence of infection. This highlights the importance of considering repeat endoscopy to evaluate for alternative causes (especially treatable causes, such as CMV) when a patient with inflammatory bowel disease initially improves with treatment then suddenly worsens.
Figure: Figure 1. Initial flexible sigmoidoscopy (top image). Repeat colonoscopy following upadacitinib rescue therapy (bottom two images).
Figure: Figure 2. Admission timeline and CRP trend.
Disclosures: Reid Herran indicated no relevant financial relationships. Samuel Wilcox indicated no relevant financial relationships. Gal Hodish indicated no relevant financial relationships. Asma Nusrat indicated no relevant financial relationships. Jiaqi Shi indicated no relevant financial relationships. Abhishek Satishchandran indicated no relevant financial relationships. Rutwik Sharma indicated no relevant financial relationships. Shrinivas Bishu indicated no relevant financial relationships. Syed Hassan indicated no relevant financial relationships. John Byrn indicated no relevant financial relationships. Haley Mertens indicated no relevant financial relationships. Anastasia Wasylyshyn indicated no relevant financial relationships. Peter Higgins: AbbVie – Consultant. Jeffrey Berinstein indicated no relevant financial relationships.
Reid Herran, MD1, Samuel Wilcox, MD1, Gal Hodish, MPH1, Asma Nusrat, MD1, Jiaqi Shi, MD, PhD1, Abhishek Satishchandran, MD, PhD2, Rutwik Pradeep. Sharma, MD3, Shrinivas Bishu, MD1, Syed A. Hassan, MBBS1, John Byrn, MD1, Haley Mertens, MD4, Anastasia Wasylyshyn, MD1, Peter D. R.. Higgins, MD, PhD, MSc1, Jeffrey Berinstein, MD, MS1. P1255 - No Stone Left Unturned: Rapid Induction of Remission With Upadacitinib Followed by Cytomegalovirus (CMV)-Colitis in a Hospitalized Patient With Crohn’s Disease (CD), ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
