The Bug Blockade: CMV-Induced Terminal Ileum Stricture

Abstract

Cytomegalovirus (CMV) colitis is typically found in patients that are immunocompromised and is rarely found in immunocompetent patients. Patients with CMV colitis present with nonspecific GI symptoms mainly abdominal pain, nausea, vomiting, and diarrhea. CMV ileitis has been primarily described in AIDS patients and is found in 4% of CMV cases affecting the GI tract. In this case, we present an immunocompetent patient who presented with a high grade small bowel obstruction (SBO) secondary to CMV ileocolitis causing a terminal ileum stricture. The patient is a 60-year-old immunocompetent, HIV-negative black male recently admitted with SBO. CT scan of his abdomen showed several centimeters of circumferential wall thickening of his terminal ileum (TI), and colonoscopy was unsuccessful due to bowel prep. He was a poor candidate for surgery given CHF with an EF of 20%. He was planned for outpatient colonoscopy after two weeks of Prednisone for presumed Crohn's disease. Patient had persistent abdominal pain requiring re-hospitalization. Colonoscopy showed ulcerations and erosions in the TI and cecum with a TI stricture that could not be traversed with biopsies taken. Repeat CT showed high grade SBO. He underwent successful laparotomy and ileocecal resection and resection of stenosis with side-to-side functional end-to-end anastomosis. Colonoscopy biopsy samples showed crypt distortion, ulceration and immunohistochemical staining was positive for CMV inclusions. The resected specimen confirmed viral cytopathic change with multiple superficial ulcerations and vasculature containing stromal cells with viral inclusions positive for CMV. There was no histologic features to support IBD. Patient had symptom resolution and was discharged home.1475_A Figure 1. Colonoscopy showing high grade stricture in the terminal ileum through which the colonoscope could not be traversedCMV ileitis is rare in immunocompetent patients. A systematic review on immunocompetent patients with CMV in any organ in 2008 described 60 patients with CMV colitis. This study found no significant difference in mortality for patients with CMV colitis treated with antiviral agents. There is only one other case report of a patient with a CMV-induced colonic stricture presenting as an acute bowel obstruction in an immunocompetent adult. This is the only case of CMV terminal ileocolitis with primary ileal involvement that caused acute SBO in an immunocompetent adult. There are no clear guidelines in the management of CMV ileocolitis; however, surgical intervention of bowel obstruction provided good outcomes in both cases.1475_B Figure 2. Colonoscopy biopsy showing evidence of CMV inclusion (arrow).1475_C Figure 3. Histology with positive immunohistochemical staining for CMV intranuclear viral inclusions.