Rapid Induction of Remission With Upadacitinib Followed by Cytomegalovirus Colitis in a Hospitalized Patient With Crohn’s Disease

Sep 30, 2026

A 60-year-old woman with acute severe Crohn’s colitis achieved a rapid initial response to off-label, high-intensity upadacitinib, but later developed clinical deterioration. She ultimately underwent colectomy for suspected refractory Crohn’s disease after worsening symptoms despite no early endoscopic signs of infection. Surgical pathology revealed quiescent Crohn’s disease with cytomegalovirus colitis, highlighting a discordance between initial endoscopic evaluation and subsequent histopathologic findings.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages4

Reading Time10 min

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Abstract

Introduction

Case Report

Initial Presentation and Evaluation

Treatment and Clinical Course

Endoscopy and Pathology

ACG CASE REPORTS JOURNAL CASE REPORT | INFLAMMATORY BOWEL DISEASE Rapid Induction of Remission With Upadacitinib Followed by Cytomegalovirus Colitis in a Hospitalized Patient With Crohn’s Disease Reid Herran, MD 1 , Samuel Wilcox, MD 1 , Gal Hodish, MPH 1 , Asma Nusrat, MD 1 , Jiaqi Shi, MD, PhD 1 , Abhishek Satishchandran, MD2 , Rutwik Sharma, MD2 , Shrinivas Bishu, MD, FACG 1 , Syed A. Hassan, MBBS 1 , John Byrn, MD 1 , Andrea Todisco, MD 1 , Haley Mertens, MD 1 , Anastasia Wasylyshyn, MD 1 , Peter D. R. Higgins, MD, PhD 1 , and Jeffrey A. Berinstein, MD 1 1 University of Michigan, Ann Arbor, MI 2 University of Michigan Health-Sparrow, Lansing, MI ABSTRACT A 60-year-old woman with acute severe Crohn’s colitis hada rapid initial response to off-label, high-intensity upadacitinib;however, she subsequently demonstrated clinical deterioration ultimately undergoing colectomy for suspected refractory Crohn’s disease. Surgical pathology unexpectedly revealed quiescent Crohn’s disease with cytomegalovirus colitis, despite no initial endoscopic evidence of infection. KEYWORDS: Crohn’s disease; cytomegalovirus; upadacitinib; IBD ABBREVIATIONS: CD, Crohn’s disease; CMV, cytomegalovirus; CRP, C-reactive protein; H&E, hematoxylin and eosin; IBD, inflammatory bowel disease; IV, intravenous; MR, magnetic resonance INTRODUCTION Crohn’s disease(CD), a chronic, relapsing inﬂammatory disorder that can affect any part ofthe gastrointestinal tract, is characterized by bloody diarrhea, abdominal pain, and weight loss and can lead to complications including stricture, ﬁstula, or abscess. Patients with CD who develop severe symptoms or Crohn’s-related complications often require hospitalization for rapid induction of treatment to improve symptoms and prevent progression of complications. There are no clear, disease-speciﬁc guidelines for patients hospitalized with Crohn’s; instead, management strategies often focus on addressing speciﬁc complications or are extrapolated from protocols established for acute severe ulcerative colitis, particularly when patients present with acute severe Crohn’s colitis. Generally, acute severe ulcerative colitis guidelines recommend initial ﬂexible sigmoidoscopy within 24–72 hours of admission to assess disease severity and to rule out cytomegalovirus (CMV) .1 However, there is no consensus recommendation for second-look endoscopy when clinical status fails to improve or worsens. Escalation to rescue therapy or surgical intervention is based on lack of clinical response after 3–5 days, not on repeat endoscopic ﬁndings.1 We present the case of a 60-year-old woman hospitalized with acute severe Crohn’s colitis, who experienced rapid clinical improvement following initiation of upadacitinib followed by clinical deterioration, prompting semiurgent colectomy. Pathology revealed quiescent CD with CMV colitis, despite no initial endoscopic evidence of infection. CASE REPORT A 60-year-old woman with a history of anoxic brain injury and CD (diagnosis previously ulcerative colitis but changed to CD based on discovery of penetrating perianal disease) previously on Lialda, hydrocortisone enemas, and prednisone, presented with uncontrolled rectal pain and bloody diarrhea. Upon arrival, vital signs were stable and labs were notable for hemoglobin 10 g/dL, ACG Case Rep J 2026;13:e01961 . doi:10 . 14309/crj.0000000000001961. Published online: January 9, 2026 Correspondence: Reid Herran, MD ([herranre@med.umich.edu](herranre@med.umich.edu)) . ACG Case Reports [Journal / Volume 13 acgcasereports.com 1](Journal / Volume 13 acgcasereports.com 1) Herran et al Rapid Induction of Remission With Upadacitinib Figure1.(A)Endoscopy image from initial flexible sigmoidoscopy showing erythematous, edematous, friable, and severely ulcerated mucosa.(B) Endoscopy image from relook colonoscopy with yellow arrow showing healing ulcer. (C) Endoscopy image from relook colonoscopy with yellow arrows showing healin

FAQs

What treatment was initiated, and how did the patient respond initially?

Off-label, high-intensity upadacitinib was started. The patient experienced rapid improvement in bloody diarrhea and normalization of CRP after 6 days.

Why did the patient ultimately undergo colectomy?

She developed clinical deterioration despite an initial response, leading to colectomy for suspected refractory Crohn’s disease.

What did surgical pathology reveal compared with early endoscopic findings?

Pathology showed quiescent Crohn’s disease with cytomegalovirus colitis, despite no initial endoscopic evidence of infection.

Sep 30, 2026

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