Cytomegalovirus Enteritis in an Immunocompetent Host

Abstract

Purpose: Introduction: Cytomegalovirus (CMV), a DNA virus is a member of the herpes virus family. CMV infection may affect all parts of the gastrointestinal tract, most commonly the esophagus and the colon. It is most often seen in immunocompromised patients. Small bowel involvement is rare. We herein present a case of an immunocompetent woman with isolated CMV infection of the small bowel. Case Report: A 65 year old Chinese woman was hospitalized with profuse diarrhea, vomiting, abdominal pain, and fever. Her past history was significant for hypertension, depression, osteoarthritis, hysterectomy and breast cancer 8 yrs ago treated with lumpectomy and radiation. Her medications included Lotrel, Celebrex, Prozac, Neurontin and Xanax. She was a non smoker and denied any drug use. On physical examination, the patient appeared ill. Her temperature was 101°F, heart rate 142 beats/min and blood pressure 100/72 mmHg. Her abdominal exam was notable for diffuse tenderness with no rebound. Laboratory values on admission were notable for an elevated creatinine but otherwise normal. Her blood and stool cultures were negative. Abdominal computed tomography showed thickening of the mid to distal small bowel. A small bowel follow through showed mucosal edema and ulcerations in the same area. Colonoscopy with intubation of the terminal ileum was normal including random biopsies. HIV test was negative. Her symptoms persisted and she was then taken for laparoscopy where a segment of abnormal small bowel was resected. Histological examination showed atypical cells with intranuclear inclusions. Immunoperoxidase stain for CMV was strongly positive. A high titer of IgM antibodies to CMV confirmed the diagnosis. Antiviral therapy was initiated and the patient recovered. Discussion: CMV infection in immunocompetent individuals is usually asymptomatic, or may produce a mononucleosis-like illness. It generally resolves without treatment. Small bowel involvement is very rare in immunocompetent individuals. A Medline search produced only 7 cases of CMV enteritis in immunocompetent subjects. The ages ranged from 18 to 68 years. Diarrhea was present in all the patients, abdominal pain in 5 cases and fever in 3 cases. Most patients were treated conservatively and symptoms resolved. Four required surgery for intestinal perforation or strictures. The characteristic histological findings of CMV enteritis are cytomegalic inclusion bodies in the endothelial cells of the capillaries. Ganciclovir and foscarnet are the primary treatment agents for clinically significant CMV infection. In conclusion, CMV enteritis is rare in immunocompetent patients but should be considered in the differential diagnosis of acute enteritis.