CMV Colitis in an HIV Positive Patient with CD4 Greater Than 200

Abstract

Case Report A 28-year-old male known to have HIV was admitted with a one-week history of worsening fatigue, nausea, vomiting, 2 kg weight loss, and constipation. Blood pressure was 110/70 mmHg. Heart rate was 105 bpm and body temperature was 37.2 C. On physical examination, the patient looked dehydrated. His abdomen was tender to palpation without guarding. Bowel sounds were normal. Initial lab work showed sodium at 130 mEq/l, albumin at 2.2 g/dl, and white blood count at 15.9 K/cmm with normal differentials. Blood cultures were negative. On admission, his CD4 count was 223 cells/ml and viral load was 5350 copies per ml. Three months prior, his CD4 count was 666 cells/ml with 1960 HIV RNA copies per ml. A kidney, ureter, and bladder (KUB) xray study showed small bowel obstruction. A nasogastric tube was inserted. Computed tomography (CT) of the abdomen showed multiple air and fluid filled loops of small bowel with marked edema of distal small bowel. Colonoscopy revealed congested and erythematous mucosa with skip areas within the proximal, middle, and distal transverse colon and congestive mucosa within the terminal ileum with prominent Peyer’s patches. Serum cytomegalovirus (CMV) PCR was 3250 IU/mL. Histological findings in colonic biopsies revealed active inflammation with ulceration (Figure 1) and characteristic large cells (Figure 2). CMV infection could be confirmed immunohistochemically (Figure 3). The patient was started on IV ganciclovir. Highly active anti-retroviral therapy (HAART) was initiated with efavirenz, emtricitabine, and tenofovir. The patient improved. He was discharged on ganciclovir 450 PO BID and HAART. Three weeks later, the patient was seen at primary care physician’s office with clinical improvement and repeat serum CMV PCR was negative.