Prisma Health-University of South Carolina School of Medicine Columbia, SC, United States
Shayan Noorani, DO1, William Webster, DO2, Edwin Hayes, MD3 1Prisma Health-University of South Carolina School of Medicine, Columbia, SC; 2University of South Carolina School of Medicine-Prisma Health, Columbia, SC; 3University of South Carolina - Prisma Health, Columbia, SC
Introduction: CMV colitis is a common presentation in immunosuppressed patients such as those with HIV/AIDS, organ transplant, malignancy, or those on chronic immunosuppression/steroids. Symptoms are generally non-specific although important clinical clues are diarrhea, hematochezia, and abdominal pain. HIV positive patients typically have CD4 counts less than 50 to 100.
Case Description/Methods: A 45 year old male without significant PMH presented to the ED with complaints of chronic diarrhea for 8-9 months with 10-15 episodes of watery stools daily and 80-pound weight loss. He denied any bright red blood per rectum or melena. Temp was 99 F, BP 99/68, HR 111 with a RR of 20 on room air. CT abdomen showed diffuse wall thickening concerning for infection versus inflammatory colitis. HIV test was positive. CD4 count was 36 with a viral load 37,763. CMV IgG serology was positive although clinical significance was uncertain given prevalence of CMV infection and persistent antibodies from possible previous infection. Cryptosporidium, rotavirus, c. difficile, comprehensive stool cultures were negative. Colonoscopy showed multiple aphtous ulcers throughout the colon that measured 4-15mm without stigmata of bleeding. Biopsies taken during endoscopy were positive for CMV with intra-nuclear inclusion bodies. After discharge, symptoms resolved after initiation of HAART therapy coupled with his 6-week course of valganciclovir.
Discussion: It is vital to assess for CMV colitis in all HIV positive patients while ruling out additional opportunistic infections that can cause diarrhea. Many methods of diagnosis are available, however the most effective is colonoscopy with adjunctive CMV immuno-staining of a colonic mucosal biopsy. Most importantly, an “owl-eye appearance” of intra-nuclear inclusion bodies should be seen. Immunohistochemistry is the “gold standard” for diagnosing CMV colitis and should be included in the comprehensive assessment in any newly diagnosed HIV patient with diarrhea. Seropositivity can also be found in the acute (IgM) or chronic (IgG) phase (or prior exposure). “Punched-out” ulcers found during colonoscopy are also associated with a higher number of these intra-nuclear inclusion bodies on staining; this is found in 70-80% of patients. Effective treatment is available for HIV-positive patients as they can be given an anti-viral such as valganciclovir. Foscarnet is also an available option. Medication should be usually given for 21-28 days or until clinical improvement.
Figure: A: Histological slide of the colon mucosa biopsy with formalin immunostaining demonstrating intranuclear inclusion bodies with an "owl eye" appearance. B: Image taken during the colonoscopy demonstrating a "punched-out" ulcer that can typically be found in CMV colitis.
Shayan Noorani indicated no relevant financial relationships.
William Webster indicated no relevant financial relationships.
Edwin Hayes indicated no relevant financial relationships.
Shayan Noorani, DO1, William Webster, DO2, Edwin Hayes, MD3. P2286 - No More Missed Opportunities: Cytomegalovirus Colitis as the Initial Presentation of HIV/AIDS Infection, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.