Potential Role of Upadacitinib in Cytomegalovirus Colitis Recurrence

Abstract

Background: Cytomegalovirus (CMV) colitis is a common complication in patients with ulcerative colitis (UC), which is often associated with immunosuppressive therapies including steroids, azathioprine, and biologics such as infliximab. Although CMV infections related to upadacitinib, a Janus kinase (JAK) inhibitor, have been reported, they typically occur after prolonged use. Consequently, early onset CMV colitis following the initiation of JAK inhibitors has not been extensively recognised.

Case report: We present the case of a 68-year-old Japanese woman with refractory UC who developed CMV colitis that initially improved but worsened shortly after starting upadacitinib. The patient improved following upadacitinib discontinuation and CMV-specific treatment. This case suggests that early onset CMV colitis after upadacitinib initiation is clinically significant and highlights the importance of monitoring lymphocyte counts and CMV antigen levels during JAK inhibitor therapy.

Conclusion: These findings provide valuable insights into the early risk of CMV reactivation and may guide future management strategies for patients with UC undergoing JAK inhibitor treatment.

Learning points: This case provides insights into managing cytomegalovirus (CMV)-related adverse effects in patients receiving Janus kinase (JAK) inhibitors.The risk of CMV disease, including CMV colitis, should be considered owing to lymphocyte reduction during upadacitinib treatment.

Keywords: Cytomegalovirus colitis; JAK inhibitors; ulcerative colitis; upadacitinib.

Figure 1

Clinical course of this case. Abbreviation: HD, hospital day; VCM, vancomycin; CFPM, cefepime; GCV, ganciclovir; CMV, cytomegalovirus. Number of CMV antigen–positive cells in 50,000 leukocytes

Figure 2

Endoscopic findings and positive immunohistochemistry (IHC) staining for cytomegalovirus (CMV) in colon biopsies. A) First colonoscopy (on day 2) reveals extensive map-like ulcers in the sigmoid colon; B) Time of recurrence (day 31): extensive map ulceration of the sigmoid colon worsened, and the mucosa was prone to bleeding.; C–D) Positive IHC staining for CMV in colon biopsies on hospital days 2 (C) and 31 (D). Bar: 20 μm.

Figure 3

Reports on cytomegalovirus (CMV) disease and lymphopenia associated with Janus kinase (JAK) inhibitors using VigiBase in the literature. There were 41 reports on CMV disease associated with JAK inhibitors, and there were 124 reports on lymphocytopenia. However, no study has documented both conditions simultaneously. The JAK inhibitors include tofacitinib citrate, baricitinib, upadacitinib, filgotinib maleate, and itacitinib.