Asif A. Hitawala, MD, Katherine Falloon, MD, Sebouh Setrakian, MD, Madhusudhan R. Sanaka, MD; Cleveland Clinic Foundation, Cleveland, OH
Introduction: Norovirus gastroenteritis is a self-limiting illness that is treated with supportive care. In immunocompromised patients, however, it is known to cause prolonged illness. Treatment remains controversial. We present a case of an immunocompromised patient with chronic norovirus gastroenteritis.
Methods: A 45–year-old Caucasian male presented to the emergency room with nausea, vomiting, loose stools up to 8/day, and 15-pound weight loss. He had a past medical history of common variable immune deficiency (CVID) with CVID associated enteropathy, vitiligo, history of extra-nodal marginal B-cell lymphoma, and celiac disease. Five months prior, he had a CVID enteropathy flare up and was prescribed oral steroids. Post steroids, he developed acute organizing pneumonia and was hospitalized. He had diarrhea which was treated with supportive care. Stool studies were positive for Norovirus 2. On admission, he was hemodynamically stable, and physical examination was remarkable for hypopigmented patches secondary to vitiligo. Abdomen had positive bowel sounds and was soft, non-tender, and non-distended. Laboratory workup was as shown in table 1. Stool studies were positive for fecal lactoferrin and Norovirus 2. The rest of the infectious workup was negative. The patient was diagnosed with CVID enteropathy flare and was started on intravenous methylprednisolone 20 mg three times a day. He had mild improvement in his symptoms. Colonoscopy was performed and was grossly unremarkable. Random colon biopsies revealed active cryptitis but did not show a paucity of plasma cells or intraepithelial lymphocytosis, as shown in figure 1. There were no histological signs of inflammatory bowel disease and staining for cytomegalovirus infection was negative. The patient was discharged on prednisone 40 mg once a day and nitazoxanide 500 mg for 14 days. Steroids helped only minimally, but after starting nitazoxanide, he had significant improvements in his symptoms and the frequency of his bowel movements decreased to 2-3 per day. At six months, he has been doing well with no reported adverse effects. Discussion: This case demonstrates that immunocompromised patients with gastrointestinal manifestations can have prolonged norovirus infection, which might cause flare-ups of underlying gastrointestinal conditions. Hence, treatment of norovirus infection in such patients should be considered, with nitazoxanide a potentially effective treatment.
Serum Laboratory Results
Hematoxylin and eosin stain of a random colon biopsy revealing active neutrophilic infiltration of the crypts with no significant architectural abnormality
Disclosures: Asif Hitawala indicated no relevant financial relationships. Katherine Falloon indicated no relevant financial relationships. Sebouh Setrakian indicated no relevant financial relationships. Madhusudhan Sanaka indicated no relevant financial relationships.