A case of infectious mononucleosis in a patient with ulcerative colitis on infliximab

Abstract

A 19 year old woman with ulcerative colitis presented to our clinic with low grade fevers, fatigue, nausea, dizziness, anorexia, and swollen neck glands. Her symptoms developed after receiving induction and two maintenance doses of infliximab. Her physical exam was notable for bilateral large, tender submandibular lymph nodes.  Her laboratory values revealed an elevated C-reactive protein, a normal white blood cell count, but prominent lymphocytes, and a positive heterophile antibody.  Tumor necrosis factor (TNF- α) is a central mediator in chronic inflammation and, thus, has been a target of treatment in chronic inflammatory disorders, such as inflammatory bowel disease (IBD). It also plays an important role in the immune response and host defense, especially in the control of viral infections. Increased rates of bacterial infection in patients treated with anti-TNF-α is a known risk and, recently, there have been investigations into risks of other opportunistic infections. However, few studies have looked at the risk of viral infections and anti-TNF-α use. As a result, there are no (or few) guidelines for treatment of patients who develop a viral infection, such as Epstein-Barr virus, while being treated with an anti-TNF-α agent. Many of the studies assessing the possible association between anti-TNF-α use and viral infections have been case reports. Therefore, in order for physicians to better treat these immune compromised patients, more needs to be dedicated to investigating the risk of viral infections and in turn, how best to monitor, prevent, and treat patients who develop viral infections while on immunosuppressants, such as anti-TNF-α agents.