P4415 - Cytomegalovirus Infection as the Initial Presentation With Ulcerative Colitis

Lena Kawji, MD, MS¹, Michael Tran, MD¹, Sudha Pandit, MD^2
1Louisiana State University Health, Shreveport, LA; ²LSU Health, Shreveport, LA

Introduction: Cytomegalovirus (CMV) is an opportunistic pathogen that mostly affects immunocompromised individuals or those on immunosuppressive therapies. We present an unusual case of CMV colitis as the initial presentation of ulcerative colitis (UC) in a patient.

Case Description/Methods: Patient is a 59-year-old male with no past medical history who presents to the emergency room with the complaint of a one month history of bloody diarrhea. Patient reports watery diarrhea intermittently being mixed with blood which is occurring more frequently over the last two weeks. Patient denies abdominal pain, nausea, vomiting, fever, or chills. Patient denies recent changes or starting new medications, sick contacts, or recent travel out of the United States. On physical exam, abdomen is soft, non-tender, and nondistended. Digital rectal exam was negative for blood. Patient admitted to the hospital for further evaluation. Workup including Clostridium difficile, Shiga toxin, ova & parasites, and stool culture were negative. WBC 11.36 K/uL, albumin 3.0 g/dL, CRP 2.30 mg/dL, and calprotectin 2,391 mcg/g. Colonoscopy was performed which showed inflammation and aphthous ulcers in the transverse, descending, sigmoid, and rectum. Mucosal findings suggestive of UC Mayo 2. Segmental colon biopsies showed features of chronic active colitis in the transverse, descending, sigmoid, and rectum. Immunostain for CMV was positive. Patient was treated with valganciclovir for 14 days. Patient underwent a repeat colonoscopy about four weeks post-treatment which showed continuous inflamed, edematous, ulcerated mucosa with loss of vascular pattern from the rectum to distal transverse colon, consistent with UC Mayo 2. The patient was started on vedolizumab and patient had a good response.

Discussion: CMV has been shown to have an association with UC, but is often seen in patients who are on immunosuppressive therapies such as steroids, immunomodulators, or biologics. CMV colitis being the initial presentation with UC in a patient not on immunosuppressive therapy is not as common. CMV infection prevalence in patients with UC ranges from 2 to 38%⁽¹⁾. With increased severity of UC and medical refractoriness of the disease, the higher the risk of CMV colitis and the poorer the prognosis. The prevalence of CMV reactivation in patients with severe UC is 4.5-16.6%⁽²⁾. In conclusion, concomitant CMV infection should be considered in patients found to have UC regardless of their immunosuppression status.



Disclosures:


Lena Kawji, MD, MS¹, Michael Tran, MD¹, Sudha Pandit, MD². P4415 - Cytomegalovirus Infection as the Initial Presentation With Ulcerative Colitis, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.