A case of cytomegalovirus-associated multiple gastric ulcers in ulcerative colitis

Abstract

Dear Editor, Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) that affects the colon to variable extents. Extracolonic manifestations like peripheral arthropathy, erythema nodosum, episcleritis, pyoderma gangrenosum, and anterior uveitis are often observed in UC patients. However, in contrast to Crohn’s disease, which can involve the whole gastrointestinal tract, UC is known not to affect other hollow visci, except the colon. We present a case of multiple, deep, and excavating gastric ulcerations mimicking ulcers in active UC lesions. The gastric ulcers healed after discontinuing immunosuppressive therapy, and cytomegalovirus (CMV) was found in gastric and colonic tissues at later pathologic review. A 50-year-old woman visited our hospital complaining of abdominal pain and hematochezia. She had been diagnosed with ulcerative proctitis some 4 years previously and treated with oral and rectal aminosalicylates and rectal budesonide. Because of aggravated abdominal pain and hematochezia, she visited our emergency unit and was admitted. Sigmoidoscopic findings and pathologic examination of rectal biopsy specimens were consistent with active stage of chronic UC. She was administered with intravenous glucocorticoid with central venous hyperalimentation, intrarectal aminosalicylates, and glucocorticoid. On the 14th day in the hospital, she complained of epigastric discomfort, and subsequent esophagogastroduodenoscopy (EGD) showed multiple shallow and deep ulcerations with erosions affecting the whole stomach. A rapid urease test and histologic examination revealed neither the presence of Helicobacter pylori nor the evidence of malignancy. Under the impression of acute gastric mucosal lesion (AGML), intravenous proton pump inhibitor (PPI) and oral antacid were started. On the 17th day in the hospital, the computed tomography performed due to a localized sustained pain in the right lower quadrant abdomen suggested microperforation of the right-side colon. Because the patient rejected surgical treatment, intravenous broad-spectrum antimicrobials were started. On the 28th day in the hospital, the second EGD showed multiple gastric ulcers with increased diameters, and because PPI had been administered for only 2 weeks, treatment was continued. However, on the 30th day in the hospital, an acute ischemic cerebral infarction developed in the frontal lobe, and 14 days later, a larger infarction developed in the left parietal lobe. To prevent further infarction-associated damage, anticoagulation therapy was started, but due to aggravated hematochezia, anticoagulation was stopped, and anti-platelet treatment was started. On the 42nd and 63rd days in the hospital, the third and fourth EGDs showed increased numbers of multiple gastric ulcers with more increased diameters together with mucosal bridging folds. On the 54th day in the hospital, the second sigmoidoscopy showed active ulcerations, and intravenous ganciclovir was started because superimposed CMV infecInt J Colorectal Dis (2007) 22:1419–1420 DOI 10.1007/s00384-006-0230-6