Baton Rouge General Medical Center Baton Rouge, LA, United States
Jeremy Polman, DO, MS, MBA, Melissa Bunke, MD, Rameela Mahat, MD, Oleana Lamendola, MD Baton Rouge General Medical Center, Baton Rouge, LA
Introduction: CMV colitis typically presents with fever, abdominal pain, and diarrhea with intermittent hematochezia. This disease is typically seen in patients with underlying immunocompromising illness or in patients taking immunosuppressive medication. However, there have been rare reports of CMV colitis in immunocompetent patients.
Case Description/Methods: A 59 year old female presents with six months of intermittent hematochezia, crampy epigastric pain, and six episodes of diarrhea per day. She also complains of weakness and fatigue over the same time period. She has no history of chronic gastrointestinal disease. At time of initial evaluation, the patient was noted to be hypotensive, had bright red blood per rectum, and hemoglobin of 6 g/dL. After stabilization with 2 units of packed red blood cells, EGD and colonoscopy were completed. EGD demonstrated normal mucosa in the esophagus, stomach, and proximal duodenum. Colonoscopy revealed many large, non-bleeding ulcerations located at the ileocecal valve, ascending colon, transverse colon, and descending colon. Biopsies of the right and left colon were obtained. Patient remained hemodynamically stable and tolerated endoscopy well, thus was discharged the following morning with gastroenterology follow up. Ultimately, the colon biopsies demonstrated focal active colitis with ulceration with fibrinopurulent exudate. Immunostaining for cytomegalovirus (CMV) was positive for suspected viral inclusions compatible with CMV related colitis. Biopsies were negative for dysplasia or malignancy. The patient was notified of biopsy results and prompted to return to the hospital for initiation of treatment and further evaluation, which did not reveal immunocompromising states or immunosuppressive medication use.
Discussion: Interestingly, the patient in the above case had biopsy proven CMV colitis with relatively minimal symptoms on presentation. Based on previous literature, immunocompetent individuals with CMV colitis typically present with severe, life threatening infection or complications. One meta-analysis of outcomes in CMV colitis infections in the immunocompetent patient demonstrated death in about 31.8% of patients greater than the age of 55. Along with immunocompromised states, patients with ulcerative colitis, age greater than 65, and diabetes mellitus are at increased risk of CMV colitis. The rarity of CMV colitis in the immunocompetent patient may lead to a delay in the diagnosis and initiation of treatment, ultimately increasing mortality rates.
Figure: A: Image of ileocecal valve ulceration obtained during colonoscopy. B: Image of descending colon ulceration obtained during colonoscopy. C: Immunohistochemical stain of colon biopsy demonstrating cytomegalovirus inclusion bodies viewed at 20x objective.
Disclosures: Jeremy Polman indicated no relevant financial relationships. Melissa Bunke indicated no relevant financial relationships. Rameela Mahat indicated no relevant financial relationships. Oleana Lamendola indicated no relevant financial relationships.
Jeremy Polman, DO, MS, MBA, Melissa Bunke, MD, Rameela Mahat, MD, Oleana Lamendola, MD. P0187 - A Strange Diagnosis of Cytomegalovirus Colitis in an Immunocompetent Patient, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.