S2281 CMV Colitis Mimicking as IBD Flare-Up in Immunocompetent Patient

Abstract

INTRODUCTION: Although almost 70 % of human beings are likely to be infected with CMV, the majority, being immunocompetent, are unlikely to manifest. Cytomegalovirus (CMV) colitis rarely occurs in immunocompetent patients. Usually, CMV colitis occurs in immunocompromised individuals but there have been reports in immunocompetent individuals as well. Here, we present a case of a 64 year old female initially presenting as IBD flare-up but later getting diagnosed with CMV colitis. CASE DESCRIPTION/METHODS: A 64-year-old woman, with a past medical history of HTN, type II diabetes, and GERD, IBD - Crohn's type on mesalamine, with recently done EGD and colonoscopy, presented to the hospital for abdominal pain and bloody stools for one month. When she came to the hospital, her WBCs were elevated, and she also had elevated lactate, ferritin but the rest of her labs were unremarkable. Subsequently, a CAT scan of Abdomen and Pelvis showed non-specific colitis. Gastroenterology service recommended starting the patient on Solu-Medrol for a possible Crohn’s Disease Flare Up. Other stool studies were negative. Over the course of her hospitalization, the patient underwent colonoscopy which showed severe inflammation and was also started on Infliximab due to unresponsiveness to treatment. Strongyloides serologies were checked and came back negative as well. The pathology results from colonoscopy came back and the findings were consistent with Cytomegalovirus (CMV) colitis. CMV IgG Ab checked came back positive and viral load came back at 7400 U/L. It was decided to treat the patient with Ganciclovir. The patient reported improvement and was able to tolerate her diet. She was subsequently discharged on valganciclovir. On subsequent follow up reported the resolution of her signs and symptoms. DISCUSSION: CMV colitis occurs in immunocompromised individuals but there have been reports in immunocompetent individuals as well. The mechanism is unclear but it has been hypothesized that CMV superinfects already inflamed mucosa. It is also stated that MHC proteins are upregulated leading to an autoimmune response. The treatment of choice for CMV colitis remains ganciclovir. The association between cytomegalovirus infection and inflammatory bowel disease challenges both the clinicians and the pathologists to establish the correct diagnosis and to prescribe the most appropriate form of therapy, therefore a high suspicion should be there for CMV colitis in Immunocompetent IBD patients as well who are not responding to treatment.Figure 1.: CT Scan of Abdomen and Pelvis showing prominent diffuse colonic wall thickening.