Cytomegalovirus colitis combined with Clostridium innocuum as a cause of lower GI bleeding in a patient with COVID-19

Abstract

A 67-year-old woman who presented with fever received a diagnosis of COVID-19 infection and was admitted to the medicine ward. She had a history of hypertension and diabetes. On day 4 of hospitalization, owing to progressive dyspnea and oxygen desaturation, she received intubation and mechanical ventilator support. She received remdesivir, dexamethasone, empiric antibiotics, enoxaparin, and tocilizumab during her hospitalization. On day 24, the patient developed bloody stools, and her hemoglobin level decreased from 11.7 g/dL to 9.2 g/dL. Because of persistent bleeding, she underwent colonoscopy, which revealed colitis and ulcer bleeding at the rectum (A). CT showed wall thickening of the lower part of the rectum (B). A pathologic study of the biopsy specimen showed enlarged nuclei and viral inclusions in both the cytoplasm and the nuclei (C). Immunohistochemical stain was positive for cytomegalovirus (CMV) antigen (D). The result of a blood CMV DNA polymerase chain reaction was positive, and the diagnosis of CMV infection was confirmed. In addition, there was growth of Clostridium innocuum in the stool culture. Her bleeding subsided after ganciclovir and metronidazole treatment, and she was extubated smoothly on day 38. Here we illustrate a COVID-19 patient who presented with lower GI bleeding caused by CMV coinfection and growth of C innocuum simultaneously. Endoscopy plays a crucial role in the treatment of patients with GI bleeding. All authors disclosed no financial relationships. Commentary The healthier you are the healthier you stay; the sicker you are the sicker you get. This case reflects this axiom. This unfortunate patient experienced severe respiratory failure secondary to COVID-19 infection. Colonoscopy revealed a dramatic "punched out" ulcer, highly suggestive of a viral colitis, and indeed the patient was found to have a CMV infection. She was also found to harbor C innocuum, which, despite its name, should not be confused with C difficile. C innocuum is an anaerobic gram-positive rod that is considered to be a variant of normal gut flora. C innocuum usually behaves in a pathogenic manner in patients who are immunocompromised, as was clearly the case with this patient. C innocuum is often seen to cause illness in patients after organ transplantation, most commonly renal transplantation. Fortunately, this patient appears to have done well after aggressive therapy for her COVID-19 infection. Douglas G. Adler, MD, FASGE, GIE Senior Associate Editor, Co-Director, Center for Advanced Therapeutic Endoscopy (CATE), Porter Adventist Hospital, PEAK Gastroenterology, Denver, Colorado Mohamed O. Othman, MD, Associate Editor for Focal Points