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Various toxicities and lack of efficacy: case report A 30-year-old woman developed pancytopenia, lymphopenia, leucopenia and cytomegalovirus (CMV) infection leading to CMV pneumonia during treatment with azathioprine and prednisolone for ulcerative colitis (UC). Additionally, she exhibited lack of efficacy with ganciclovir for CMV infection [routes not stated; not all dosages stated]. The woman, who had UC, was hospitalised in Germany with a suspicion of steroid-refractory relapse of her UC. In 2007, she had been diagnosed with UC at which time she had received mesalazine and unspecified therapy with improvement. Following relapses and extra-intestinal complaints, her therapy was switched to prednisolone [initial dosage not stated] and azathioprine 125 mg/day in November 2016. Her concomitant medication included unspecified oral contraceptive. On hospitalisation, she had a fever of up to 39.0°C with arthralgias and chills for a about two-and-half weeks, which were compatible with the symptoms of her relapses, and therefore, the symptoms were interpreted as the start of a flare-up. Following hospitalisation at another hospital, the immunosuppression was initially increased by prednisolone 50 mg/day and azathioprine 150 mg/day. No improvement was noticed under unspecified antipyretic medication. Additionally, abdominal pain and bloody stools with mucous continued to occur. She received mesalazine along with unspecified topical therapy. One-off evidence of aerobic sporulation in a blood culture bottle was observed, which was thought to be because of contamination. Abdominal CT showed left bowel wall thickening and hepatosplenomegaly. The fever persisted. She was then moved to the current hospital. On hospitalisation (current presentation), she reported increasing shortness of breath and dry cough as well as clear sputum since the previous day. She exhibited tachycardia, tachypnoea and fever. Tests showed bilateral fine-bubble basal rattling noises ("crackles/rales"), left lower abdominal pressure pain and upper abdomen without resistance or muscular defense. In addition, local calf tenderness was observed. Laboratory tests showed the following: elevated CRP and pancytopenia with mild leucopenia, which was because of severe lymphopenia. On admission, the woman was treated with ganciclovir, piperacillin/tazobactam and cotrimoxazole [trimethoprim/ sulfamethoxazole] to prevent the development of opportunistic infections. Her azathioprine therapy was discontinued, and prednisolone dose was decreased gradually. Subsequently, a CT of her thorax demonstrated extensive pneumonic infiltrates in both the sublobes. She received mesalazine for her underlying UC. Laboratory chemical findings showed a high replicative CMV with a viral load of 130000 copies/mL. A pneumocystis infection was excluded. Despite treatment with ganciclovir, a further worsening in her respiratory situation with progressive infiltrates was observed, initially leading to non-invasive ventilation and ultimately to an endotracheal intubation. She developed