Acute Cytomegalovirus Colitis Mimicking Exacerbation of Ulcerative Colitis: Precipitating or Coincidental?

Abstract

Cytomegalovirus colitis is an uncommon cause of diarrhea in older adults, despite the high seroprevalence of cytomegalovirus in the general population: 40%-70% of adults in higher socioeconomic groups, and up to 90% of adults in lower socioeconomic groups.1Lockwood M.R. Liddle J. Kitsanta P. Cytomegalovirus colitis—an unusual cause of diarrhoea in an elderly woman.Age Ageing. 2006; 35: 198-200Crossref PubMed Scopus (23) Google Scholar The majority of primary cytomegalovirus infections in immunocompetent adults are asymptomatic or associated with mild mononucleosis-like syndrome. Cytomegalovirus produces characteristic cytopathic effects, consisting of a large 25- to 35-μm cell containing a basophilic intranuclear inclusion, which is sometimes surrounded by a clear halo. Immunohistochemistry of the biopsied tissue using monoclonal antibodies and in situ DNA hybridization enhances the sensitivity of the histologic analysis.2Carter D. Olchovsky D. Pokroy R. Ezra D. Cytomegalovirus-associated colitis causing diarrhea in an immunocompetent patient.World J Gastroenterol. 2006; 12: 6898-6899PubMed Google Scholar An 87-year-old man with history of inflammatory bowel disease in the form of ulcerative colitis on mesalazine was admitted to our hospital with hourly, watery, nondysenteric diarrhea associated with constant, severe diffuse lower abdominal pain and weight loss. One month before admission, he presented with similar symptoms and was discharged home from our Emergency Department on antibiotics and steroids after an abdominal computed tomography scan showed features suggestive of colitis/diverticulitis (Figure). Two weeks before presentation, he again experienced unrelenting abdominal pain and watery diarrhea. He was diagnosed with ischemic colitis after suggestive visual features on sigmoidoscopy and subsequently discharged home after a 3-day inpatient care stay with a pending colonic biopsy result. This was later interpreted as ulcerative colitis versus ischemic colitis. Physical examination revealed an oriented and distressed elderly man with dry mucous membrane, hyperactive bowel sounds, and diffuse lower abdominal tenderness without peritoneal signs. Laboratory findings were relevant for elevated lactate of 2.7. Complete blood count and basic metabolic panel were unremarkable. Blood, stool, and Clostridium difficile toxin were negative. On hospital day 2, he was transferred to our intensive care unit for management of hypovolemic shock and underwent repeat sigmoidoscopy. Gross sigmoidoscopy report again showed features suggestive of ulcerative colitis, and the patient was empirically started on metronidazole, levofloxacin, steroids, and mesalazine. Surgical consultation favored hemicolectomy in the setting of refractory diarrhea. Histological report of the most recent colonic biopsy revealed rare endothelial cells with cytoplasmic/nuclear inclusions characteristic of cytomegalovirus infection. Cytomegalovirus DNA/polymerase chain reaction was positive. The patient was treated with intravenous ganciclovir 5 mg/kg every 12 hours for 4 weeks and, ultimately, was discharged after 2 weeks with complete resolution of his symptoms. Clinically significant gastrointestinal cytomegalovirus infection typically occurs in immunocompromised patients. Acute cytomegalovirus infection is not uncommon, and is often underestimated in patients with refractory inflammatory bowel disease, as it is thought that cytomegalovirus infects areas of active inflammatory bowel disease, causing colonic injury.3Maher M.M. Nassar M.L. Acute cytomegalovirus infection is a risk factor in refractory and complicated inflammatory bowel disease.Dig Dis Sci. 2009; 54: 2456-2462Crossref PubMed Scopus (78) Google Scholar Treatment of cytomegalovirus infection with ganciclovir has recently been shown to be an effective strategy in patients with steroid-refractory active ulcerative colitis.4Kim Y.S. Kim Y.H. Kim J.S. et al.IBD Study Group of the Korean Association for the Study of Intestinal DiseasesThe prevalence and efficacy of ganciclovir on steroid refractory ulcerative colitis with cytomegalovirus infection: a prospective multicenter study.J Clin Gastroenterol. 2012; 46: 51-56Crossref PubMed Scopus (70) Google Scholar Cytomegalovirus DNA load determined in inflamed intestinal tissue can be used to predict resistance to steroid treatment and to 3 drug regimens in ulcerative colitis.5Roblin X. Pillet S. Oussalah A. et al.Cytomegalovirus load in inflamed intestinal tissue is predictive of resistance to immunosuppressive therapy in ulcerative colitis.Am J Gastroenterol. 2011; 106: 2001-2008Crossref PubMed Scopus (141) Google Scholar Acute cytomegalovirus colitis should be ruled out before implementing aggressive immunosuppressive or surgical interventions in patients with refractory or complicated inflammatory bowel disease. Clinicians should be aware that inflammatory bowel disease can lead to a state of immunosuppression in which opportunistic infections can masquerade and mislead management of exacerbations.