Not All that Perforates is Ulcerative Colitis: A Case of Severe Fulminant Cytomegalovirus Colitis Leading to Total Colectomy With End Ileostomy in New Diagnosis of Inflammatory Bowel Disease
Background:
Cytomegalovirus (CMV) can cause severe multi organ infections in immunocompromised individuals. CMV colitis often presents with nonspecific symptoms such as diarrhea, abdominal pain and fever, and can lead to complications such as bowel perforation, colectomy, and death. This case report details the clinical course of a 76-year-old male with a new diagnosis of steroid refractory ulcerative colitis who developed concomitant CMV colitis with colonic perforation.
Methods:
Here we report a case of 76-year-old male with no previous gastrointestinal disease who presents with recurring nausea, vomiting, hematochezia and diarrhea for 3 months. CT A&P with contrast demonstrated acute moderate/severe diffuse pancolitis. CT angiography was notable for mild to moderate stenosis at the origin of the celiac axis with an unremarkable superior mesenteric artery. Colonoscopy demonstrated chronic active inflammation in all segments of the colon and active proctitis with ulceration in the rectum, normal terminal ileum endoscopically and on biopsy. <italic>Clostridioides difficile</italic>, GI pathogen and CMV PCR as well as adenovirus were negative. Calprotectin >3000 ug/g, ESR 42 mm/hr. Initial presentation was attributed as indeterminant colitis, likely ischemic colitis. Patient was discharged on mesalamine and pentoxifylline. He was soon readmitted for hemorrhagic shock requiring blood transfusion and vasopressor support. EGD showed gastritis and some clean-based antral ulcers. Flexible sigmoidoscopy showed severe continuous colitis with multiple punched out ulcers. Pathology from sigmoidoscopy was non-specific. Infectious workup negative. The patient was started on methylprednisone and transferred to our institution for further management.
Results:
On arrival, he was afebrile and hemodynamically stable with mild left lower quadrant tenderness to palpation and diarrhea with dark blood and mucus. Infliximab (5 mg/kg IV x 1) given with no response. A total colectomy was done which identified intraoperatively a splenic flexure colonic perforation. Post-op pathology showed severely active fulminant colitis with diffuse ulcerations and attenuated crypts and mucosa with diminished folding, suggesting background of chronic colitis and extensive colonic CMV involvement. CMV and CD 68 immunostain positive cells were dispersed in the areas of inflammation. Antiviral therapy was initiated post operatively. CMV PCR viral load was initially 57,000 IU/mL which improved to viral load 12,500 IU/mL at discharge with treatment. Glucocorticoids stopped after 7 days.
Conclusions:
CMV colitis is commonly seen in immunocompromised patients. Patients with underlying inflammatory bowel disease (IBD) are also susceptible to have CMV infection due to mucosal disruption. CMV can be an innocent bystander in active flares of ulcerative colitis or more often the culprit for deterioration when increase load burden. Steroid use alone can increase perforation risk. Furthermore, pentoxifylline (PTX) use has been observed in vitro and in vivo to reactivate CMV in immunosuppressed patients by stimulatory effect on cell enhancer/promoter leading to HCMV antigen expression and replication. PTX use should be limited in high risk CMV colitis patients. Prompt diagnosis and treatment of infection etiology such as CMV may alter the outcome of IBD flare. Viral infections will need to be carefully evaluated during a possible IBD flare especially in patients with steroid-resistant colitis.
