Clinical Features and Outcomes of Cytomegalovirus Colitis or Pouchitis in Patients with Inflammatory Bowel Disease

Abstract

Purpose: To evaluate the clinical features and outcomes of cytomegalovirus (CMV) colitis or pouchitis complicating the course of inflammatory bowel disease (IBD). Methods: A centralized diagnostic index was utilized to identify all patients with confirmed IBD and CMV colitis or pouchitis who were evaluated at Mayo Clinic Rochester between 1992 and 2001. Medical records were abstracted for demographics, clinical features and outcomes. Results: Fourteen patients with IBD and CMV colitis or pouchitis were identified, ten with ulcerative colitis (UC) (71%), three with Crohn's disease (CD) (21%), and one with indeterminate colitis (7%). Thirteen patients had a previously established diagnosis of IBD, while one was diagnosed with CMV and IBD concurrently. Present medications included steroids in 86% and immunosuppressives in 37% (only 14% were on neither). In 12 patients, CMV was identified after failure of conventional medical therapy. In two cases, CMV was not suspected preoperatively and was diagnosed by review of the surgical specimen. CMV diagnosis was based on characteristic histologic findings in 13 cases, and on colitic symptoms plus serologies and viral culture of blood in one case. CMV serologies were performed in 7 cases; IgG was positive in 5 (71%) and IgM was positive in 3 (43%). In 2 cases, both IgG and IgM were negative despite positive biopsy findings. In 11, CMV treatment consisted of intravenous ganciclovir and withdrawal of immunosuppressives; in 9 patients (82%), remission of disease was achieved and colectomy avoided. In the 2 other patients with a pre-operative diagnosis of CMV, surgery was the primary treatment due to severity of disease. Two patients presented with CMV pouchitis; one improved with therapy (ganciclovir and withdrawal of immunosuppressives), while the other did not. Conclusions: CMV colitis or pouchitis may complicate the course of IBD. CMV superinfection should be considered in all patients presenting with a severe IBD exacerbation, especially those who are refractory to steroids and immunosuppressives. Treatment involves anti-viral therapy, mainly ganciclovir, and withdrawal of immunosuppressive agents. This leads to improvement of underlying IBD in most patients, and can often avoid, or at least delay, the need for surgical intervention.