3148 CMV Colitis in a Patient With Diffuse Large B-Cell Lymphoma (DLBCL) and Crohn's Disease

Abstract

INTRODUCTION: Cytomegalovirus (CMV) colitis, while uncommon in immunocompetent hosts, can occur relatively frequently in patients with IBD. Here we present the case of a woman with Crohn's disease and DLBCL with biopsy evidence suggesting CMV colitis. CASE DESCRIPTION/METHODS: A 59 year-old woman with Crohn's disease and DLBCL (on 12 mg dexamethasone daily) presented with abdominal pain and gastrointestinal bleeding. The patient was having sharp, intermittent, left-sided epigastric pain, similar to her prior Crohn's flares, and 5-6 bloody bowel movements per day, requiring 6 units of packed red blood cell transfusions at an outside hospital. She initially received mesalamine, with some relief of symptoms. On exam, the patient was in mild discomfort and had a soft, non-tender, non-distended abdomen. Initial laboratory testing was notable for a normal WBC count, hemoglobin 9.3, ALP 721, ALT 157, AST 102, ESR 2, CRP 5.2, and CMV viral load of 6,806,760. Abdominal CT and CT angiography showed colonic musical enhancement and mural edema indicative of probable colitis, without evidence of active bleeding. Empiric treatment with ganciclovir was initiated for presumed CMV colitis while the medical team awaited receipt of reports from the outside hospital. The patient had intermittent bleeding for several days that eventually resolved spontaneously. A prior colonoscopy report from the outside hospital ultimately showed colonic ulceration and endoscopic features “highly suggestive of CMV infection.” The immunopathology report of colon tissue biopsies showed ulceration and numerous enlarged cells with intranuclear and intracytoplasmic eosinophilic inclusions, consistent with CMV infection. DISCUSSION: This patient's presentation demonstrates the diagnostic challenge that can occur with IBD patients. Typical presenting symptoms for CMV colitis, including abdominal pain, diarrhea, and intestinal bleeding, can overlap significantly with symptoms of a non-infectious IBD flare. A high degree of clinical suspicion and appropriate laboratory testing is therefore needed to distinguish these two disease processes. Diagnosis is typically established by a combination of CMV viral load and immunohistochemical testing of colonic biopsy specimens. CMV colitis can be treated with antiviral medications, as in this case, but is associated with poor overall clinical outcomes, possibly requiring colectomy. After completing treatment for CMV colitis, the decision to reintroduce immunomodulatory therapy is made on a case-by-case basis.