Cytomegalovirus Colitis in a Patient with Crohnʼs Disease

Abstract

Purpose: A 21-year-old woman with a history of Crohn's disease presented with diffuse abdominal pain, nausea, vomiting, and watery diarrhea that had persisted for five days in spite of being on her usual maintenance treatment. The patient was hospitalized two weeks prior for a Crohn's flare that required treatment with IV Solu-Medrol®. On admission, the patient had a temperature of 38.4′C, HR of 78 bpm, BP of 110/50 mmHg, and a RR of 18/min with saturations at 98% on RA. The patient had diffuse abdominal tenderness on physical examination without rebound tenderness. Computed tomography of the abdomen (Panel A) showed diffuse inflammation extending from the ileum to the proximal descending colon. Colonoscopy revealed extensive mucosal ulcerations in the descending colon. A biopsy from a mucosal ulcer (arrow Panel B) was obtained. Treatment for C. difficile diarrhea did not resolve her symptoms. A hematoxylin-eosin stain displayed the characteristic owl's eye appearance (arrow Panel C). Cytomegalovirus (CMV) immunostaining was positive on histopathology (arrows Panel D). After the diagnosis was made, the patient was treated with IV ganciclovir with resolution of her colitis and clinical symptoms after two weeks. At one year follow up, there was no relapse of infection in spite of being on long term treatment with immunomodulators. CMV colitis is not uncommon in patients with inflammatory bowel disease on immunosuppressive medications. One must have a high index of suspicion, and at times multiple modalities for diagnosis may be necessary because patients with IBD present with atypical symptoms and signs.FigureFigure