Viral infections in inflammatory bowel disease: Tips and tricks for correct management

Table 1 Summary of recommendations for the prevention and management of viral infections in inflammatory bowel disease

Infection	Screening prior to IM	Vaccination	Prophylaxis	Diagnosis	Therapy
HAV	IgG anti-HAV	Inactivated HAV vaccine; (2 doses, 0-6 mo)	-	IgG anti-HAV	Supportive
HCV	Ab anti-HCV; If positive HCV-RNA	-	-	Anti-HCV Ab; if positive HCV-RNA	DAA[62]
HBV	HBsAg, anti-HBs, anti-HBc;If positive HBV-DNA	Accelerated double-dose; (0, 1, 2 mo); If no response, re-vaccination; (0, 1, 2 mo) at a double-dose	In HBsAg+ (or antiHBc+); Entecavir 0.5 mg/d;Tenofovir, start 2 wk prior to IM	Exacerbation: ↑ AST/ALT; 100-fold rise HBV DNA	Entecavir 0.5-1 mg/daily; Tenofovir
HPV	Cervical smear test	bi/quadri/nine-valent;Women: 9-26 yr, Men: 11-23 yr	-	Cervical smear test	-
Influenza	-	Inactivated non-live trivalent	-	RT-PCR	Single neuraminidase inhibitor
HIV	HIV p24 Ag and Ab	-	-	Acute infection: RT-PCR	ART[99]
HSV	History of herpes lesions	-	Frequent/severe recurrence:acy-, valacy-, famci-clovir	Viral culture, H&E, RT-PCR	acyclovir, valacyclovir, and famciclovir
CMV	In steroid refractory patients	-	-	CMV inclusions in H&E + IHC followed by tissue RT- PCR	IV ganciclovir 5-7.5 mg/kg twice daily for 2 wk
VZV	VZV IgG/IgM	VZV vaccine: 4-3 wk before IM; HZ vaccine (recombinant): 2 doses, 0-3/6 mo	After exposure: VZV-Ig	RT-PCR on skin lesions	IV or PO acyclovir, valacyclovir, and famciclovir
EBV	EBV IgG/IgM	-	-	IgM VCA + and IgG EBNA -	-
SARS-CoV2	Recommended (test based on availability)	Recommended; mRNA-based; adenoviral vector	-	nasopharyngeal swabs; PCR-SARS-CoV-2	-

IM: Immune-modifier; DAA: Direct-acting antiviral; RT-PCR: Real-time polymerase chain reaction; IV: Intra-venous; PO: Per-os; HAV: Hepatitis A virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus; HPV: Human papillomavirus; HIV: Human immunodeficiency virus; HSV: Herpes simplex virus; CMV: Cytomegalovirus; VZV: Varicella zoster virus; EBV: Epstein-Barr virus; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2.

Table 2 Diagnostic approach to inflammatory bowel disease patients with infectious symptoms

Symptoms cluster	Potential viral pathogens	Diagnostic work up
Fever	VZV, HBV, HCV, EBV, HIV, SARS-CoV-2	Medical history, physical examination
		Blood cell counts, PCR, PCT
		VZV, HBV, HCV, EBV and HIV Ab
		Hemocultures
		Urine analysis and culture
		Stool examinations
		Strongyloidiasis serology
		Chest X-ray
		Infectious disease specialist consult
Respiratory	Influenza, SARS-CoV-2 (Bilateral interstitial infiltrates)	Chest X-ray or US
		SaO2% < range → CT
		Pneumonia:
		Sputum cultures
		NPS for SARS-CoV-2/influenza virus Legionella and pneumococcal U-Ag
		Bronchoalveolar lavage
Gastrointestinal	HSV, CMV, EBV, Adenovirus, Astrovirus, Norovirus, Rotavirus, Sapovirus	Rule out potential enteric infection:
		Stool cultures
		Examination for parasites
		C. difficile toxin testing
		Multiplex molecular assays
Central nervous system	CMV, HSV, VZV, JC virus	Neurological advice
		CSF cultures and PCR
		MRI
Cutaneous	HSV, VZV	Dermatological consult
		PCR on recent lesion

CRP: C-reactive protein; PCT: Procalcitonin; US: Ultrasound; CT: Computed tomography; NPS: Nasopharyngeal swab; U-Ag: Urinary antigen; CSF: Cerebrospinal fluid; PCR: Polymerase chain reaction; MRI: Magnetic resonance imaging; HAV: Hepatitis A virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus; HPV: Human papillomavirus; HIV: Human immunodeficiency virus; HSV: Herpes simplex virus; CMV: Cytomegalovirus; VZV: Varicella zoster virus; EBV: Epstein-Barr virus; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; JC: John Cunningham virus; C. difficile: Clostridium difficile.