- Email: [email protected]
IL-2 is a gradually proved potential therapeutic target for hepatocellular carcinoma
Correspondence / Digestive and Liver Disease 46 (2014) 288–291
continuing encouragement in caring the patient and reporting the case. The Institutions of some of the Authors of this manuscript are recipient of funding from the European Community’s Seventh Framework Programme (FP7/2007-2013) under agreement No. HEALTH-F2-2009-241762 for the project FLIP. References [1] Bunchorntavakul C, Bahirwani R, Drazek D, et al. Clinical features and natural history of hepatocellular adenomas: the impact of obesity. Alimentary Pharmacology and Therapeutics 2011;34:664–74. [2] Loria P, Carulli L, Bertolotti M, et al. Endocrine and liver interaction: the role of endocrine pathways in NASH. Nature Reviews Gastroenterology and Hepatology 2009;6:236–47. [3] Ballestri S, Lonardo A, Romagnoli D, et al. Ultrasonographic fatty liver indicator, a novel score which rules out NASH and is correlated with metabolic parameters in NAFLD. Liver International 2012;32:1242–52. [4] Brunt EM, Janney CG, Di Bisceglie AM, et al. Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions. The American Journal of Gastroenterology 1999;94:2467–74. [5] Brunt EM, Wolverson MK, Di Bisceglie AM. Benign hepatocellular tumors (adenomatosis) in nonalcoholic steatohepatitis: a case report. Seminars in Liver Disease 2005;25:230–6.
Fabio Nascimbeni Stefano Ballestri Department of Internal Medicine, Endocrinology, Metabolism and Geriatrics, Operative Unit of Internal Medicine and Metabolism, Nuovo Ospedale Civile S. Agostino-Estense, University of Modena and Reggio Emilia, Modena, Italy Luca Di Tommaso Department of Medical Biotechnologies and Translational Medicine, Operative Unit of Anathomic Pathology, Humanitas Clinical Institute, University of Milan, Milan, Italy Micaela Piccoli Operative Unit of Surgery, Nuovo Ospedale Civile S. Agostino-Estense, University of Modena and Reggio Emilia, Modena, Italy Amedeo Lonardo ∗ Department of Internal Medicine, Endocrinology, Metabolism and Geriatrics, Operative Unit of Internal Medicine and Metabolism, Nuovo Ospedale Civile S. Agostino-Estense, University of Modena and Reggio Emilia, Modena, Italy ∗ Corresponding
author at: Nuovo Ospedale Civile S. Agostino-Estense – Baggiovara, Via Giardini 1355, 41126 Modena, Italy. Tel.: +39 0593961807; fax: +39 0593961335. E-mail address: [email protected] (A. Lonardo) 2 September 2013 Available online 1 November 2013 http://dx.doi.org/10.1016/j.dld.2013.09.018
IL-2 is a gradually proved potential therapeutic target for hepatocellular carcinoma Sir, With great interest, I read the recent article by Cheng et al. which demonstrated that liver specific expression of IL-2 exhib-
289
ited strong anti-tumour efficacy in mouse model of liver cancer established by intrahepatic transplantation of murine H22 hepatoma cells [1]. To date, interleukin-2 (IL-2), a pleiotropic cytokine, regulates the activation, differentiation and growth of T lymphocytes, natural killer (NK), and lymphokine-activated killer cells. It can also promote the production of cytokines including interferon-gamma (IFN-␥), tumour necrosis factor-alpha (TNF-␣), and interleukin-6 (IL-6) [2]. Recently, Ha et al. established the stable attenuated Salmonella typhimurium strain expressing the IL-2 gene (TPI). Notably the study showed that the proportion of CD4+ T cells in TPI group was higher than that in TPG (an attenuated S. typhimurium strain carrying green fluorescent protein gene), and TP (an attenuated S. typhimurium strain) groups; additionally, the proliferation activity of splenic lymphocyte was significantly enhanced in the TPI group [3]. Generally it is understood that CD4+ T cell is a key subset of immune cells mediating anti-tumour immune defence while cancer cells can trigger CD4+ T cell apoptosis to induce immune evasion during tumour progression. In fact, the immune responsiveness in hepatocellular carcinoma (HCC) consists of impaired CD4+ T cell function and suppressed CD4+ T cell proliferation. Moreover, Pedroza-Gonzalez et al. reported that CD4+ /CD25+ /Foxp3+ regulatory T cells (Tregs) accumulated in the liver of patients with HCC, which led to the suppression of autologous tumour-specific T cell responses [4]. Due to the ability to capture, process, and present antigens to T cells, dendritic cells (DCs) are considered as pivotal vehicles to deliver therapeutic cancer vaccine candidates, as evident by the findings that vaccination with cytokine-transfected DCs induce the rejection of tumours in different animal models. Specifically, by transfection of DCs with AdIL-2 vector containing fragments of the IL-2 genes, Yang and his colleagues proved that IL-2-DCs can potently enhance antigen-specific antitumour efficacy through inhibiting tumour growth [5]. Taken together, the transfection of DCs and CD4+ T cells with IL-2 gene would be potential strategies for the immunotherapy of patients with HCC. Although cell supernatant containing IL-2 protein has limited effect on proliferation and migration of HepG2 cells, the weight of transplanted tumour in the TPI group was significantly decreased compared with TPG and TP group, consistent with the further increased infiltration of lymphocytes in the tumour from TPI group mice. Notably, oral TPI could really prevent the proliferation of cancer since oral administration of an attenuated S. typhimurium to express a truncated human IL-2 resulted in a decreased metastatic hepatic tumour burden [3]. In general, these observations provide a promising strategy of targeting IL-2 for the treatment of HCC through immune modulation. Unravelling the relationship as well as the underlying mechanism between IL-2 and development of HCC may provide specific targets for therapeutic intervention of this disease. Conflict of interest statement None declared. Acknowledgement This work was partly supported by the grants from the key program of the National Natural Science Foundation of China (No. 81273526). References [1] Cheng W, Miao L, Zhang H, et al. Induction of interleukin 2 expression in the liver for the treatment of H22 hepatoma in mice. Digestive and Liver Disease 2013;45:50–7.
290
Correspondence / Digestive and Liver Disease 46 (2014) 288–291
[2] Haagsman AN, Witkamp AC, Sjollema BE, et al. The effect of interleukin-2 on canine peripheral nerve sheath tumours after marginal surgical excision: a double-blind randomized study. BMC Veterinary Research 2013;9: 155. [3] Ha XQ, Yin Q, Zhao HB, et al. Inhibitory effects of the attenuated Salmonella typhimurium containing the IL-2 gene on hepatic tumors in mice. Journal of Biomedicine and Biotechnology 2012;2012:946139. [4] Pedroza-Gonzalez A, Verhoef C, Ijzermans JN, et al. Activated tumor-infiltrating CD4+ regulatory T cells restrain antitumor immunity in patients with primary or metastatic liver cancer. Hepatology 2013;57:183–94. [5] Yang JY, Li X, Gao L, et al. Co-transfection of dendritic cells with AFP and IL-2 genes enhances the induction of tumor antigen-specific antitumor immunity. Experimental and Therapeutic Medicine 2012;4:655–60.
Tao Xu a,b Xiao-ming Meng a,b a School of Pharmacy, Anhui Key Laboratory of Bioactivity of Natural Products, Anhui Medical University, Hefei, China b Institute for Liver Diseases of Anhui Medical University, Anhui Medical University, Hefei, China Hong-wei Yao Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY, USA Jun Li a,b,∗ School of Pharmacy, Anhui Key Laboratory of Bioactivity of Natural Products, Anhui Medical University, Hefei, China b Institute for Liver Diseases of Anhui Medical University, Anhui Medical University, Hefei, China a
∗ Corresponding author at: School of Pharmacy, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui Province, China. Tel.: +86 551 65161001; fax: +86 551 65161001.
E-mail addresses: [email protected], [email protected] (J. Li) Available online 13 November 2013 http://dx.doi.org/10.1016/j.dld.2013.10.003
Acute cytomegalovirus infection as a possible trigger for pulmonary thromboembolism in a patient with steroid-refractory ulcerative colitis Dear Editor, A 72-year old woman was admitted for exacerbation of ulcerative colitis (UC). She was on maintenance therapy with mesalazine (2400 g/daily). Upon admission, she had 8 bowel movements/day of bloody stools and an axillary temperature of 37.6 ◦ C; Lichtiger colitis activity index score (LCAIS) was 14 (>10 indicates severe colitis). She also presented swelling at the left leg. Laboratory exams revealed neutrophilic leucocytosis (16,800 cells/mm3 , lymphocytes count 1540), anaemia (haemoglobin 11.3 g/dl), elevated C-reactive protein (71 mg/l, normal value <5) and D-dimer (1800 ng/ml, normal value <400). Doppler ultrasound (DUS) revealed a massive thrombosis of the left iliac–femoral–popliteal venous axis and a partial thrombosis of the right common femoral vein. A thoracic and abdominal contrast-enhanced computed tomography (CT) scan revealed bilateral pulmonary embolism (PE) with pulmonary infarction areas and confirming deep venous thrombosis. The patient started enoxaparin (100 IU/kg twice daily) and intravenous methylprednisolone (60 mg daily). A Clostridium difficile toxin assay was negative. Serology for cytomegalovirus
(CMV) infection (both IgG and IgM) and serum CMV-DNA were positive (22,213 copies/ml). Immunohistochemical analysis of rectal samples was positive for CMV infection. After three days of therapy, no significant clinical response was observed (LCAIS 13), and intravenous ganciclovir was begun. Prothrombotic risk factors were excluded: antithrombin III, protein C and S activity, anti-cardiolipin antibodies, lupus anticoagulant, Factor V Leiden, G20210A prothrombin-gene mutation and homocysteine levels were normal. After one week of antiviral therapy fever and intestinal symptoms had significantly improved (LCAIS 7), and serum CMV-DNA had decreased to 2690 copies/ml. Ganciclovir was switched to oral valganciclovir and steroids were tapered and switched to oral administration. After ten days, DUS revealed partial recanalization of the iliac–femoral veins and a chest CT confirmed regression of the PE, and oral anticoagulation with warfarin was started. The patient was discharged two weeks after admission. Inflammatory bowel disease (IBD) patients have an increased risk of venous thromboembolism (VTE), mainly due to acquired prothrombotic factors, including active inflammation [1]. We hypothesized that in this case, acute CMV infection could be implicated in determining both the steroid-refractory condition and VTE. The role of CMV infection in the exacerbation of UC still remains a widely debated issue; indeed, current data fail to clarify if CMV worsens the course of colitis or is instead only an “innocent bystander” [2]. However, when active CMV infection is diagnosed and leads to a worsening of intestinal inflammation, it may result in a poor response to conventional therapy; in some of these cases, specific antiviral treatment may be needed to avoid colectomy [2]. Several cases of VTE associated with acute CMV infection have been described, although, this is the second report of this association in a patient with IBD [3]. Babyatsky et al. have described the case of a 30 year-old man with a history of undetermined colitis who presented with portal vein thrombosis following acute CMVmononucleosis syndrome [4]. Several prothrombotic effects of CMV infection have been described. The infection of endothelial cells seems to change the endothelium phenotype from anticoagulant to procoagulant, enhancing platelet and leucocyte adhesion and migration [5]. In addition, CMV-infected endothelial cells could be targeted by natural killer cells, leading to further damage of vessel surfaces. The ability of CMV to activate factors X and VIII and to stimulate thrombin generation has also been reported [5]. Finally, a few cases of acute CMV infection and VTE have been associated with the transitory presence of IgM anti-cardiolipin antibodies [4]. In conclusion, our report underlines the importance of screening for CMV in all IBD patients with VTE and fever, as acute CMV infection may represent a further prothrombotic risk factor beyond active disease.
References [1] Papa A, Scaldaferri F, Danese S, et al. Vascular involvement in inflammatory bowel disease: pathogenesis and clinical aspects. Digestive Diseases 2008;26:149–55. [2] Lawlor G, Moss AC. Cytomegalovirus in inflammatory bowel disease: pathogen or innocent bystander? Inflammatory Bowel Diseases 2010;16: 1620–7. [3] Justo D, Finn T, Atzmony L, Guy N, Steinvil A. Thrombosis associated with acute cytomegalovirus infection: a meta-analysis. European Journal of Internal Medicine 2011;22:195–9. [4] Babyatsky MW, Keroack MD, Blake MA, et al. M. Case 35-2007: a 30-year-old man with Inflammatory Bowel Disease and recent onset of fever and bloody diarrhea. New England Journal of Medicine 2007;357:2068–76. [5] Squizzato A, Gerdes VE, Büller HR. Effects of human cytomegalovirus infection on the coagulation system. Thrombosis and Haemostasis 2005;9: 403–10.
continuing encouragement in caring the patient and reporting the case. The Institutions of some of the Authors of this manuscript are recipient of funding from the European Community’s Seventh Framework Programme (FP7/2007-2013) under agreement No. HEALTH-F2-2009-241762 for the project FLIP. References [1] Bunchorntavakul C, Bahirwani R, Drazek D, et al. Clinical features and natural history of hepatocellular adenomas: the impact of obesity. Alimentary Pharmacology and Therapeutics 2011;34:664–74. [2] Loria P, Carulli L, Bertolotti M, et al. Endocrine and liver interaction: the role of endocrine pathways in NASH. Nature Reviews Gastroenterology and Hepatology 2009;6:236–47. [3] Ballestri S, Lonardo A, Romagnoli D, et al. Ultrasonographic fatty liver indicator, a novel score which rules out NASH and is correlated with metabolic parameters in NAFLD. Liver International 2012;32:1242–52. [4] Brunt EM, Janney CG, Di Bisceglie AM, et al. Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions. The American Journal of Gastroenterology 1999;94:2467–74. [5] Brunt EM, Wolverson MK, Di Bisceglie AM. Benign hepatocellular tumors (adenomatosis) in nonalcoholic steatohepatitis: a case report. Seminars in Liver Disease 2005;25:230–6.
Fabio Nascimbeni Stefano Ballestri Department of Internal Medicine, Endocrinology, Metabolism and Geriatrics, Operative Unit of Internal Medicine and Metabolism, Nuovo Ospedale Civile S. Agostino-Estense, University of Modena and Reggio Emilia, Modena, Italy Luca Di Tommaso Department of Medical Biotechnologies and Translational Medicine, Operative Unit of Anathomic Pathology, Humanitas Clinical Institute, University of Milan, Milan, Italy Micaela Piccoli Operative Unit of Surgery, Nuovo Ospedale Civile S. Agostino-Estense, University of Modena and Reggio Emilia, Modena, Italy Amedeo Lonardo ∗ Department of Internal Medicine, Endocrinology, Metabolism and Geriatrics, Operative Unit of Internal Medicine and Metabolism, Nuovo Ospedale Civile S. Agostino-Estense, University of Modena and Reggio Emilia, Modena, Italy ∗ Corresponding
author at: Nuovo Ospedale Civile S. Agostino-Estense – Baggiovara, Via Giardini 1355, 41126 Modena, Italy. Tel.: +39 0593961807; fax: +39 0593961335. E-mail address: [email protected] (A. Lonardo) 2 September 2013 Available online 1 November 2013 http://dx.doi.org/10.1016/j.dld.2013.09.018
IL-2 is a gradually proved potential therapeutic target for hepatocellular carcinoma Sir, With great interest, I read the recent article by Cheng et al. which demonstrated that liver specific expression of IL-2 exhib-
289
ited strong anti-tumour efficacy in mouse model of liver cancer established by intrahepatic transplantation of murine H22 hepatoma cells [1]. To date, interleukin-2 (IL-2), a pleiotropic cytokine, regulates the activation, differentiation and growth of T lymphocytes, natural killer (NK), and lymphokine-activated killer cells. It can also promote the production of cytokines including interferon-gamma (IFN-␥), tumour necrosis factor-alpha (TNF-␣), and interleukin-6 (IL-6) [2]. Recently, Ha et al. established the stable attenuated Salmonella typhimurium strain expressing the IL-2 gene (TPI). Notably the study showed that the proportion of CD4+ T cells in TPI group was higher than that in TPG (an attenuated S. typhimurium strain carrying green fluorescent protein gene), and TP (an attenuated S. typhimurium strain) groups; additionally, the proliferation activity of splenic lymphocyte was significantly enhanced in the TPI group [3]. Generally it is understood that CD4+ T cell is a key subset of immune cells mediating anti-tumour immune defence while cancer cells can trigger CD4+ T cell apoptosis to induce immune evasion during tumour progression. In fact, the immune responsiveness in hepatocellular carcinoma (HCC) consists of impaired CD4+ T cell function and suppressed CD4+ T cell proliferation. Moreover, Pedroza-Gonzalez et al. reported that CD4+ /CD25+ /Foxp3+ regulatory T cells (Tregs) accumulated in the liver of patients with HCC, which led to the suppression of autologous tumour-specific T cell responses [4]. Due to the ability to capture, process, and present antigens to T cells, dendritic cells (DCs) are considered as pivotal vehicles to deliver therapeutic cancer vaccine candidates, as evident by the findings that vaccination with cytokine-transfected DCs induce the rejection of tumours in different animal models. Specifically, by transfection of DCs with AdIL-2 vector containing fragments of the IL-2 genes, Yang and his colleagues proved that IL-2-DCs can potently enhance antigen-specific antitumour efficacy through inhibiting tumour growth [5]. Taken together, the transfection of DCs and CD4+ T cells with IL-2 gene would be potential strategies for the immunotherapy of patients with HCC. Although cell supernatant containing IL-2 protein has limited effect on proliferation and migration of HepG2 cells, the weight of transplanted tumour in the TPI group was significantly decreased compared with TPG and TP group, consistent with the further increased infiltration of lymphocytes in the tumour from TPI group mice. Notably, oral TPI could really prevent the proliferation of cancer since oral administration of an attenuated S. typhimurium to express a truncated human IL-2 resulted in a decreased metastatic hepatic tumour burden [3]. In general, these observations provide a promising strategy of targeting IL-2 for the treatment of HCC through immune modulation. Unravelling the relationship as well as the underlying mechanism between IL-2 and development of HCC may provide specific targets for therapeutic intervention of this disease. Conflict of interest statement None declared. Acknowledgement This work was partly supported by the grants from the key program of the National Natural Science Foundation of China (No. 81273526). References [1] Cheng W, Miao L, Zhang H, et al. Induction of interleukin 2 expression in the liver for the treatment of H22 hepatoma in mice. Digestive and Liver Disease 2013;45:50–7.
290
Correspondence / Digestive and Liver Disease 46 (2014) 288–291
[2] Haagsman AN, Witkamp AC, Sjollema BE, et al. The effect of interleukin-2 on canine peripheral nerve sheath tumours after marginal surgical excision: a double-blind randomized study. BMC Veterinary Research 2013;9: 155. [3] Ha XQ, Yin Q, Zhao HB, et al. Inhibitory effects of the attenuated Salmonella typhimurium containing the IL-2 gene on hepatic tumors in mice. Journal of Biomedicine and Biotechnology 2012;2012:946139. [4] Pedroza-Gonzalez A, Verhoef C, Ijzermans JN, et al. Activated tumor-infiltrating CD4+ regulatory T cells restrain antitumor immunity in patients with primary or metastatic liver cancer. Hepatology 2013;57:183–94. [5] Yang JY, Li X, Gao L, et al. Co-transfection of dendritic cells with AFP and IL-2 genes enhances the induction of tumor antigen-specific antitumor immunity. Experimental and Therapeutic Medicine 2012;4:655–60.
Tao Xu a,b Xiao-ming Meng a,b a School of Pharmacy, Anhui Key Laboratory of Bioactivity of Natural Products, Anhui Medical University, Hefei, China b Institute for Liver Diseases of Anhui Medical University, Anhui Medical University, Hefei, China Hong-wei Yao Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY, USA Jun Li a,b,∗ School of Pharmacy, Anhui Key Laboratory of Bioactivity of Natural Products, Anhui Medical University, Hefei, China b Institute for Liver Diseases of Anhui Medical University, Anhui Medical University, Hefei, China a
∗ Corresponding author at: School of Pharmacy, Anhui Medical University, 81 Meishan Road, Hefei 230032, Anhui Province, China. Tel.: +86 551 65161001; fax: +86 551 65161001.
E-mail addresses: [email protected], [email protected] (J. Li) Available online 13 November 2013 http://dx.doi.org/10.1016/j.dld.2013.10.003
Acute cytomegalovirus infection as a possible trigger for pulmonary thromboembolism in a patient with steroid-refractory ulcerative colitis Dear Editor, A 72-year old woman was admitted for exacerbation of ulcerative colitis (UC). She was on maintenance therapy with mesalazine (2400 g/daily). Upon admission, she had 8 bowel movements/day of bloody stools and an axillary temperature of 37.6 ◦ C; Lichtiger colitis activity index score (LCAIS) was 14 (>10 indicates severe colitis). She also presented swelling at the left leg. Laboratory exams revealed neutrophilic leucocytosis (16,800 cells/mm3 , lymphocytes count 1540), anaemia (haemoglobin 11.3 g/dl), elevated C-reactive protein (71 mg/l, normal value <5) and D-dimer (1800 ng/ml, normal value <400). Doppler ultrasound (DUS) revealed a massive thrombosis of the left iliac–femoral–popliteal venous axis and a partial thrombosis of the right common femoral vein. A thoracic and abdominal contrast-enhanced computed tomography (CT) scan revealed bilateral pulmonary embolism (PE) with pulmonary infarction areas and confirming deep venous thrombosis. The patient started enoxaparin (100 IU/kg twice daily) and intravenous methylprednisolone (60 mg daily). A Clostridium difficile toxin assay was negative. Serology for cytomegalovirus
(CMV) infection (both IgG and IgM) and serum CMV-DNA were positive (22,213 copies/ml). Immunohistochemical analysis of rectal samples was positive for CMV infection. After three days of therapy, no significant clinical response was observed (LCAIS 13), and intravenous ganciclovir was begun. Prothrombotic risk factors were excluded: antithrombin III, protein C and S activity, anti-cardiolipin antibodies, lupus anticoagulant, Factor V Leiden, G20210A prothrombin-gene mutation and homocysteine levels were normal. After one week of antiviral therapy fever and intestinal symptoms had significantly improved (LCAIS 7), and serum CMV-DNA had decreased to 2690 copies/ml. Ganciclovir was switched to oral valganciclovir and steroids were tapered and switched to oral administration. After ten days, DUS revealed partial recanalization of the iliac–femoral veins and a chest CT confirmed regression of the PE, and oral anticoagulation with warfarin was started. The patient was discharged two weeks after admission. Inflammatory bowel disease (IBD) patients have an increased risk of venous thromboembolism (VTE), mainly due to acquired prothrombotic factors, including active inflammation [1]. We hypothesized that in this case, acute CMV infection could be implicated in determining both the steroid-refractory condition and VTE. The role of CMV infection in the exacerbation of UC still remains a widely debated issue; indeed, current data fail to clarify if CMV worsens the course of colitis or is instead only an “innocent bystander” [2]. However, when active CMV infection is diagnosed and leads to a worsening of intestinal inflammation, it may result in a poor response to conventional therapy; in some of these cases, specific antiviral treatment may be needed to avoid colectomy [2]. Several cases of VTE associated with acute CMV infection have been described, although, this is the second report of this association in a patient with IBD [3]. Babyatsky et al. have described the case of a 30 year-old man with a history of undetermined colitis who presented with portal vein thrombosis following acute CMVmononucleosis syndrome [4]. Several prothrombotic effects of CMV infection have been described. The infection of endothelial cells seems to change the endothelium phenotype from anticoagulant to procoagulant, enhancing platelet and leucocyte adhesion and migration [5]. In addition, CMV-infected endothelial cells could be targeted by natural killer cells, leading to further damage of vessel surfaces. The ability of CMV to activate factors X and VIII and to stimulate thrombin generation has also been reported [5]. Finally, a few cases of acute CMV infection and VTE have been associated with the transitory presence of IgM anti-cardiolipin antibodies [4]. In conclusion, our report underlines the importance of screening for CMV in all IBD patients with VTE and fever, as acute CMV infection may represent a further prothrombotic risk factor beyond active disease.
References [1] Papa A, Scaldaferri F, Danese S, et al. Vascular involvement in inflammatory bowel disease: pathogenesis and clinical aspects. Digestive Diseases 2008;26:149–55. [2] Lawlor G, Moss AC. Cytomegalovirus in inflammatory bowel disease: pathogen or innocent bystander? Inflammatory Bowel Diseases 2010;16: 1620–7. [3] Justo D, Finn T, Atzmony L, Guy N, Steinvil A. Thrombosis associated with acute cytomegalovirus infection: a meta-analysis. European Journal of Internal Medicine 2011;22:195–9. [4] Babyatsky MW, Keroack MD, Blake MA, et al. M. Case 35-2007: a 30-year-old man with Inflammatory Bowel Disease and recent onset of fever and bloody diarrhea. New England Journal of Medicine 2007;357:2068–76. [5] Squizzato A, Gerdes VE, Büller HR. Effects of human cytomegalovirus infection on the coagulation system. Thrombosis and Haemostasis 2005;9: 403–10.