Korean J Gastroenterol.  2017 Jul;70(1):44-49. 10.4166/kjg.2017.70.1.44.

Use of Novel Oral Anticoagulant to Treat Pulmonary Thromboembolism in Patient with Ulcerative Colitis Superinfected Cytomegalovirus Colitis

• Kim SH
• Jang S
• Sung Y
• Park JK
• Park Y
• Yun J
• Kang SB

• KMID: 2390784
• DOI: http://doi.org/10.4166/kjg.2017.70.1.44

Abstract

Crohn's disease and ulcerative colitis are the two major types of inflammatory bowel disease, and affect mainly the gastrointestinal tract but also have extraintestinal sequelae, such as arterial and venous thromboembolism. Thromboembolic complications, particularly pulmonary thromboembolism, can be life threatening and require prompt management with anticoagulants. Conventional vitamin K antagonists have been used for the treatment of thromboembolic complications, but the development of novel oral anticoagulants has shifted the paradigm. We report a case of a 42-year-old female with ulcerative colitis who experienced an acute flare-up due to cytomegalovirus superinfection with pulmonary thromboembolism. She was treated with oral mesalamine, intravenous steroid and ganciclovir and low-molecular-weight heparin, followed by rivaroxaban, a novel oral anticoagulant. Her symptoms resolved after treatment, and no recurrence was noted during a 6-month post-treatment follow-up.

Keyword

Inflammatory bowel disease; Ulcerative colitis; Pulmonary thromboembolism; Rivaroxaban; Cytomegalovirus

MeSH Terms

Adult
Anticoagulants
Colitis*
Colitis, Ulcerative*
Crohn Disease
Cytomegalovirus*
Female
Follow-Up Studies
Ganciclovir
Gastrointestinal Tract
Heparin, Low-Molecular-Weight
Humans
Inflammatory Bowel Diseases
Mesalamine
Pulmonary Embolism*
Recurrence
Rivaroxaban
Superinfection
Ulcer*
Venous Thromboembolism
Vitamin K
Anticoagulants
Ganciclovir
Heparin, Low-Molecular-Weight
Mesalamine
Rivaroxaban
Vitamin K

Figure

• 

  Fig. 1. Multiple longitudinal and geographic ulcerations with some denuded colonic mucosa and easy touch bleeding were noted from the distal descending colon to the rectum. CMV PCR of the tissue biopsy confirmed CMV colitis. (A) Descending colon. (B) Proximal sigmoid colon. (C) Distal sigmoid colon. (D) Rectum. CMV, cytomegalovirus; PCR, polymerase chain reaction.

• 

  Fig. 2. Chest dynamic computed tomography showed a filling defect in the lobar and segmental branches of the right pulmonary artery (arrows). (A, B) Transverse view. (C, D) Coronal view.

• 

  Fig. 3. Lower extremity computed tomography showed diffuse filling defect from the left common iliac vein to the calf veins of the lower left leg (arrows), and normal vessels of the lower right leg (arrowhead). (A) Iliac crest level. (B) Symphysis pubis level. (C) Popliteal level.

• 

  Fig. 4. Follow up chest computed tomography after 2 months of rivaroxaban treatment. The previously noted filling defect in the lobar and segmental branches of the right pulmonary artery had disappeared. (A, B) Transverse view. (C, D) Coronal view.

Reference

References

1. Owczarek D, Cibor D, Głowacki MK, Rodacki T, Mach T. Inflammatory bowel disease: epidemiology, pathology and risk factors for hypercoagulability. World J Gastroenterol. 2014; 20:53–63.

2. Papa A, Gerardi V, Marzo M, Felice C, Rapaccini GL, Gasbarrini A. Venous thromboembolism in patients with inflammatory bowel disease: focus on prevention and treatment. World J Gastroenterol. 2014; 20:3173–3179.

3. van der Hulle T, Kooiman J, den Exter PL, Dekkers OM, Klok FA, Huisman MV. Effectiveness and safety of novel oral anti-coagulants as compared with vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: a systematic review and metaanalysis. J Thromb Haemost. 2014; 12:320–328.

4. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009; 361:1139–1151.

5. Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2013; 369:2093–2104.

6. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011; 365:981–992.

7. Choi CH, Kim YH, Kim YS, et al. Guidelines for the management of ulcerative colitis. Korean J Gastroenterol. 2012; 59:118–140.

8. Grainge MJ, West J, Card TR. Venous thromboembolism during active disease and remission in inflammatory bowel disease: a cohort study. Lancet. 2010; 375:657–663.

9. Chung WS, Lin CL, Hsu WH, Kao CH. Inflammatory bowel disease increases the risks of deep vein thrombosis and pulmonary embolism in the hospitalized patients: a nationwide cohort study. Thromb Res. 2015; 135:492–496.

10. Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational corss-sectional study. Lancet. 2008; 371:387–394.

11. Cushman M, Tsai AW, White RH, et al. Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. Am J Med. 2004; 117:19–25.

12. Talbot RW, Heppell J, Dozois RR, Beart RW Jr. Vascular complications of inflammatory bowel disease. Mayo Clin Proc. 1986; 61:140–145.

13. Rosendaal FR. Venous thrombosis: a multicausal disease. Lancet. 1999; 353:1167–1173.

14. Justo D, Finn T, Atzmony L, Guy N, Steinvil A. Thrombosis associated with acute cytomegalovirus infection: a metaanalysis. Eur J Intern Med. 2011; 22:195–199.

15. Atzmony L, Halutz O, Avidor B, et al. Incidence of cytomegalovirus-associated thrombosis and its risk factors: a case-control study. Thromb Res. 2010; 126:e439–e443.

16. Schimanski S, Linnemann B, Luxembourg B, et al. Cytomegalovirus infection is associated with venous thromboembolism-a casecontrol study. J Thromb Haemost. 2009; 7(Suppl 2):418.

17. Hutten BA, Prins MH. Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism. Cochrane Database Syst Rev. 2006; (1):CD001367.

18. Chung C, Kang DH, Kim EA, Hong SH, Kong HS, Park HC. A case of pulmonary embolism in recurrent ileal crohn's disease after total colectomy. Korean J Gastrointest Endosc. 2001; 22:111–115.

19. Chung ES, Kim JH, Jung JH, et al. A case of pulmonary embolism in crohn's disease. Tuberc Respir Dis. 2009; 66:370–373.

20. Cho YH, Chae MK, Cha JM, et al. Cerebral venous thrombosis in a patient with crohn's disease. Intest Res. 2016; 14:96–101.