Crohnʼs Disease Presenting as Acute Colonic Obstruction Secondary to CMV in an Immunocompetent Patient

Abstract

Purpose: CMV colitis has been associated with inflammatory bowel disease (IBD). We report a case of a patient with large bowel obstruction who was found to have active CMV infection and later on was diagnosed with Crohn's disease. Methods: A 70-year-old male with DM, hypertension and prostate cancer was admitted with fever, severe abdominal pain, distension, nausea and vomiting. Physical examination revealed a diaphoretic, febrile, tachycardic male who was not in respiratory distress. The abdomen was distended and diffusely tender. Results: Labs showed a hemoglobin of 12.9 g/dL, WBC 23.4 K/mcL. Venous pH 7.26, lactic acid 9.4 mml/L. Stool and blood cultures were negative. Abdominal CT scan showed dilated colon, wall thickening and a narrowing area in the sigmoid colon concerning for a transitional zone. Emergent laparotomy was done for possible malignant large bowel obstruction. Laparotomy demonstrated a large obstructive sigmoid tumor. Patient underwent sigmoidocolectomy, with creations of a hartman's pouch and an end colostomy. Histology of the resected specimen suggested benign stricture with fibrosis, transmural inflammation and widespread mucosal ulcerations. He had intermittent fever post surgery despite treatment with immipenam, vancomycin, tigecycline and fluconazole. Multiple blood and urine cultures were negative. A repeat CT showed pan colitis. Colonoscopy was performed and biopsy revealed inflammation and acute CMV colitis. HIV testing was negative. Gancyclovir IV was administered for 4 weeks. The patient's clinical status improved. A repeat colonoscopy was done 6 months after discharge, histology revealed illietis and pan colitis without CMV present. A diagnosis of Crohn's disease was made and asacol treatment was started. Another repeat colonoscopy done 9 months later showed improvement of inflammation. Conclusion: CMV colitis is rare in immunocompetent patients and sometimes it is associated with IBD. On rare occasions, it can mimic colon carcinoma. In our case, obstructive CMV was the initial presentation of Crohn's disease. Elevated cytokines such as TNF-α, IFN-γ, IL-6 might be involved in reactivation of latent CMV infection which in turn exacerbates IBD. Others have suggested primary CMV infection precipitates IBD by enhancing surface antigen expression in a host predisposed to IBD. Standard treatment for CMV colitis is under debate since it is usually a self-limiting event. In our case, patient improved clinically after starting ganciclovir treatment. Ganciclovir treatment should be considered in patients who are at a higher mortality rate including those over 55 years old, and those with diabetes, renal failure, pregnancy or untreated non-hematological malignancy.