CMV Colitis: Bright Red Bleeding per Rectum as Primary Clinical Manifestation

Abstract

Introduction: Cytomegalovirus (CMV) gastrointestinal disease is an uncommon but serious complication of acquired immunedeficiency syndrome (AIDS). Recently, the incidence of CMV gastrointestinal disease has decreased substantially since the advent of highly active anti-retroviral therapy (HAART).Figure: Colonoscopy showing large ulcers at the hepatic flexure.Case: A 62-year-old male with history of HIV on HAART was sent from a nursing home for evaluation of respiratory distress with oxygen saturation of 89% on room air. On admission, the patient was noted to have supratherapeutic INR of 4.7. The patient was on warfarin for DVT. He was also found to have an acute drop in hematocrit with no obvious source of bleeding. He received packed red blood cells. He also received vitamin K to reverse coagulopathy. While in the hospital, the patient had recurrent episodes of bright red bleeding per rectum. Despite reversing coagulopathy and multiple packed red blood cell transfusions, he became hypotensive. He was transferred to ICU, where he continued to bleed. Colonoscopy was performed. The bowel preparation was suboptimal. The source of bleeding could not be identifi ed. The patient stopped bleeding spontaneously, and was later transferred to the general medical floor. The patient later had another episode of rectal bleeding. A Bleeding scan showed bleeding originating from the mid-ascending colon. A repeat colonoscopy was performed, which showed colitis with large ulcers at the hepatic flexure. The differential diagnoses that were considered at that point were Ischemia, lymphoma, MAI, amoeba and CMV. Biopsies were obtained and sent to pathology. CMV by PCR came back as 79700 copies/ml. Histopathology showed evidence of CMV colitis. The patient was treated with Ganciclovir 5 mg/kg IV every 12 hrs x 2 weeks, then 5 mg/kg once daily. He improved clinically and was discharged to the nursing home on Valaganciclovir 900 mg orally twice daily, followed by 900 mg once a day, until CD4 count becomes more than 100. Conclusion: This is a rare case of CMV colitis with gastrointestinal bleeding as the primary and only clinical manifestation.Figure: Histopathology: colonic mucosa showing giant cells with pleomorphic basophilic inclusion bodies (Owl's eyes)and inflammatory cells.