2087 Severe CMV Proctitis as the Initial Presentation of Ulcerative Proctitis

Abstract

INTRODUCTION: CMV colitis is seen in patients with IBD on long term immunosuppressive therapy; studies show the rate of seropositivity in IBD patients is the same as the general population (∼70%). Due to this there is a concern for reactivation when long term immunosuppressive therapy is initiated. Here we present the case of a patient who presented with CMV colitis prior to initiation of any therapy or diagnosis of IBD; CMV colitis in immunocompetent patients remains fairly rare. CASE DESCRIPTION/METHODS: A 30-year-old male with a history of EoE and PUD presented with seven days of painful hematochezia and constipation; he denied any fevers, however did have chills and cold sweats. He had no history of IVDA, intranasal drug use, anal sex, or risky sexual behaviors. His EoE symptoms were well controlled on PPI. Temperature was 103.2 F, he was tachycardic and tachypneic on presentation. CT revealed fecalization of the small bowel, significant stool burden, and rectal stool ball. He was started on lubiprostone and a bowel regimen with PEG-3350, he passed stool with significant decrease in abdominal distention, however he continued to have rectal pain and hematochezia. Colonoscopy was performed and showed diffuse severe inflammation with erythematous, granular, and friable mucosa in the rectum. He was started on rectal mesalamine and corticosteroid therapy. Biopsies returned showing CMV associated severe ulcerative proctitis without evidence of dysplasia. He was then started on ganciclovir and PICC was placed for 2 weeks of treatment. Repeat HIV and HIV viral load testing were done, both returning negative. On follow up in clinic he reported good control of his symptoms with oral and rectal mesalamine. Flexible sigmoidoscopy showed a rectal scar and significantly improved inflammation, biopsy revealed ulcerative proctitis. DISCUSSION: CMV colitis has been commonly associated with UC patients on immunosuppressive therapy. An increasing body of literature shows the presence of colonic CMV infection in patients with UC on therapy has been associated with decreased response to steroids and other immunosuppressive therapies. Prognosis is poor unless the infection is promptly identified and anti-viral therapy is started. It still remains a rare entity in immunocompetent patients. This raises the question if CMV testing should be done prior to initiation of immunosuppressive therapy in these patients and if CMV testing should be done regularly in patients with refractive UC flares.