Nathanial Bartosek, MD1, Ihab Kassab, MD2, Prekchha Jha, MBBS3, Fadi Odish, MD1 1Beaumont Health, Royal Oak, MI; 2Corewell Health, Royal Oak, MI; 3Corewell Health William Beaumont University Hospital, Royal Oak, MI
Introduction: Cytomegalovirus (CMV) colitis is a rare condition typically associated with immunocompromised individuals but can occasionally present in immunocompetent patients, presenting a diagnostic challenge. This case displays CMV colitis in an immunocompetent patient with a complex diagnostic evaluation.
Case Description/Methods: A 65-year-old female presented with three weeks of profuse, watery diarrhea with electrolyte abnormalities. CT abdomen revealed diffuse large bowel mucosal wall thickening concerning for pancolitis with a CRP of ~300mg/L and positive fecal lactoferrin. Colonoscopy showed inflammation in a continuous and circumferential pattern and severe (Mayo Score 3) pancolitis visually consistent with ulcerative colitis, thus steroids were considered. However, colonic tissue biopsies only revealed a hyperplastic polyp with reactive inflammation, but tissue samples were qualitative PCR positive for CMV.
The patient was started on intravenous ganciclovir. Flexible sigmoidoscopy was performed for additional biopsies, revealing linear and deep ulcerations in the descending colon. Pathology displayed granulation tissue and mild active colitis, with the pathology-based differential being infectious, diverticula-associated colitis, or Inflammatory Bowel Disease (IBD). The patient’s symptoms markedly improved following antiviral therapy and was discharged on oral valganciclovir.
Discussion: Given the noted active colitis without confirmation of IBD on two separate endoscopic biopsies, colonic tissue positive CMV PCR, and impressive clinical improvement on antivirals without steroids, it is reasonable to state CMV as the cause of findings. Despite the pronounced evidence aiding confirming CMV colitis, the possibility of underlying IBD cannot be entirely excluded. The presence of CMV infection might have been coincidental or it may have exacerbated pre-existing subclinical IBD. Careful long-term follow-up and repeat colonoscopy is essential to monitor for any recurrence of symptoms or development of IBD.
CMV can cause colitis in immunocompetent individuals, although it is rare and often underrecognized. The pathophysiology of CMV colitis in immunocompetent patients remains unclear, but it is hypothesized that local inflammation or a transient immunocompromised state might play a role. The presence of CMV infection in colonic biopsies should prompt further evaluation and antiviral treatment considerations, as timely intervention can lead to rapid clinical improvement and improved patient outcomes.
Figure: Figure: (1A,1B,1C) Endoscopic images from initial colonoscopy revealing severe, continuous, and circumferential inflammation with spontaneous bleeding and ulcerations in the Sigmoid Colon (1A,1B) and Rectum (1C). (2A,2B,2C) Repeat flexible sigmoidoscopy revealing significant linear and deep ulcerations in the Descending colon (2A), Sigmoid Colon, and Rectum (2B,2C).
Disclosures:
Nathanial Bartosek indicated no relevant financial relationships.
Ihab Kassab indicated no relevant financial relationships.
Prekchha Jha indicated no relevant financial relationships.
Fadi Odish indicated no relevant financial relationships.
Nathanial Bartosek, MD1, Ihab Kassab, MD2, Prekchha Jha, MBBS3, Fadi Odish, MD1. P2035 - Unmasking the Uncommon: CMV Colitis in an Immunocompetent Patient - A Diagnostic Challenge, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
