Journal List > Korean J Gastroenterol > v.70(1) > 1007725

Kim, Jang, Sung, Park, Park, Yun, and Kang: Use of Novel Oral Anticoagulant to Treat Pulmonary Thromboembolism in Patient with Ulcerative Colitis Superinfected Cytomegalovirus Colitis

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 anti-coagulants 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.

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.
crossref
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.
crossref
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.
crossref
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.
crossref
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.
crossref
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.
crossref
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.
crossref
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.
crossref
12. Talbot RW, Heppell J, Dozois RR, Beart RW Jr. Vascular complications of inflammatory bowel disease. Mayo Clin Proc. 1986; 61:140–145.
crossref
13. Rosendaal FR. Venous thrombosis: a multicausal disease. Lancet. 1999; 353:1167–1173.
crossref
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.
crossref
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.
crossref
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.
crossref
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.
crossref

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.
kjg-70-44f1.tif
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.
kjg-70-44f2.tif
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.
kjg-70-44f3.tif
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.
kjg-70-44f4.tif
TOOLS
Similar articles