Gastrointestinal CMV Disease in an Immunocompetent Host

Abstract

Gastrointestinal CMV is a well-described problem in patients who are immunocompromised. Rarely, gastrointestinal CMV can also affect immunocompetent patients. Here we report an immunocompetent patient with gastrointestinal CMV disease, and we discuss when to treat such patients with antivirals. An 83 year-old immunocompetent male with diabetes presented for black stool. EGD and colonoscopy showed antral ulcers, a duodenal ulcer, and scattered colonic ulcers. Biopsies came back positive for gastric, duodenal, and colonic CMV. The patient was referred to immunology whose initial impression was that the CMV was an innocent bystander. It was decided not to treat the CMV. He had no further melena. However, a repeat EGD and colonoscopy ten months later showed persistence of the CMV. A Medline search focusing on when to treat with antivirals in an asymptomatic immunocompetent patient with CMV was done. Most CMV disease occurs in patients immunocompromised by HIV, organ transplants, chronic steroids, or chemotherapy. CMV disease is exceptionally rare in the immunocompetent, being the subject of only a few case reports. Gastrointestinal CMV most often presents as diarrhea, abdominal pain, and bleeding. Treatment is usually with ganciclovir, but immunocompetent patients are often not treated with antivirals. A meta-analysis of cases of CMV colitis in immunocompetent hosts in Digestive Diseases and Sciences by Gaiatsatos and colleagues found that there was a higher mortality in patients of male gender who were older than 55 and in patients with chronic diseases. Among patients younger than 55, 50% had spontaneous resolution without antivirals, and survival for their group was 100%. However, in those older than 55, only 32% had spontaneous resolution, and survival for their group was 45%. Since our patient was both a male older than 55 and also a diabetic, we treated him with a course of oral ganciclovir. A followup colonoscopy was normal, but EGD showed persistence of the duodenal ulcer with CMV present in the biopsies. Re-treatment with IV ganciclovir is currently being pursued. Here we present a case of gastrointestinal CMV in a immunocompetent patient, and we discuss reasons to treat with antiviral therapy versus observation. The available literature supports the use of antivirals in patients older than 55 or with co-morbidities.