Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 9  |  Issue : 6  |  Page : 727-729  

A case of cytomegalovirus colitis in an immunocompetent host


1 Department of General Medicine, Government Medical College, Thrissur, Kerala, India
2 Department of General Medicine, Government Medical College, Palakkad, Kerala, India

Date of Web Publication16-Nov-2016

Correspondence Address:
P P Binny
Department of General Medicine, Government Medical College, Thrissur, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.194192

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  Abstract 

Cytomegalovirus (CMV) is a common pathogen worldwide. Clinically significant CMV infection is mostly seen in the context of immunosuppression, whether congenital, acquired, or iatrogenic. In the recent past, however, in both adults and children, an increasing number of moderate-to-severe cases of colitis have been described among immunocompetent patients. We describe a rare case of severe CMV colitis in an immunocompetent patient which resolved spontaneously.

Keywords: Colitis, cytomegalic cells, cytomegalovirus, exudative ascites, immunocompetent host


How to cite this article:
Binny P P, Sreeram B, Indira M, Andrews MA. A case of cytomegalovirus colitis in an immunocompetent host. Med J DY Patil Univ 2016;9:727-9

How to cite this URL:
Binny P P, Sreeram B, Indira M, Andrews MA. A case of cytomegalovirus colitis in an immunocompetent host. Med J DY Patil Univ [serial online] 2016 [cited 2024 Mar 29];9:727-9. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2016/9/6/727/194192


  Introduction Top


Cytomegalovirus (CMV) is an extremely common pathogen worldwide, in which 40-100% of the world's population estimated to be seropositive, especially those in developing countries. [1] CMV stays lifetime once it enters a person's body. Most of the healthy children and adults infected with CMV are asymptomatic. Others may develop a mild illness when they get infected and have the following symptoms: Fever, sore throat, fatigue, and swollen glands. The risk of getting CMV through casual contact is very small. The virus is generally passed from infected people to others through direct contact with body fluids, such as urine, saliva, or breast milk. CMV can be transmitted sexually, through transplanted organs and blood transfusions. [2]

CMV infection is usually seen in patients with weak immune system due to either chronic immunosuppressive diseases (human immunodeficiency virus [HIV], leukemia) or immunosuppressive medications for the treatment of autoimmune diseases/transplant patients or cancers. However, CMV infections can also affect those who are immunocompetent, those lacking a congenital or acquired immunodeficiency, transplant, or immunosuppressive medication. [3],[4]

Hence, CMV infections in immunocompetent hosts range from asymptomatic to CMV-induced mononucleosis, pneumonitis, hepatitis, or colitis, with asymptomatic predominating. [5] CMV affects many different organ systems, including the gastrointestinal tract. [4]

Gastrointestinal CMV infection has been mostly described in immunosuppressed patients with luminal disease, such as colitis or esophagitis. However, in both adults and children, an increasing number of moderate-to-severe cases of colitis have been described among immunocompetent patients. This case represents a rare but serious condition of CMV colitis in an immunocompetent patient which resolved spontaneously.


  Case Report Top


A 52-year-old female presented with diffuse noncolicky abdominal pain and progressively increasing abdominal distension of 4 weeks. She also had intermittent small volume, watery nonbloody stools with mucus since 2 weeks. She had low-grade fever of 2 days duration. There is no history of previous such episodes or any other significant history in the past.

On examination, patient was pale and had bilateral pitting pedal edema. Her abdomen was distended and ascites present. Respiratory system examination revealed features suggestive of right-sided pleural effusion. Her blood investigations showed leukocytosis with a total count of 61,500 and high C-reactive protein. Renal function test was normal and liver function test showed hypoalbuminemia. Stool routine examination was normal. Peripheral smear showed myeloid leukemoid reaction. Viral markers were negative for hepatitis B, C and HIV. Ultrasonography abdomen and computed tomography abdomen showed thickening of walls of ascending and transverse colon with moderate ascites. Colonoscopy showed multiple areas of discrete ulcers with surrounding erythema. Ascitic and pleural fluid tapping were done; both were consistent with exudative fluids. Fluids were sent for culture and sensitivity including tuberculosis. We considered the possibilities of inflammatory bowel disease, intestinal and peritoneal tuberculosis.

In hospital, initially patient's general condition deteriorated became tachypneic and abdominal distension increased. In view of exudative ascites and high prevalence of tuberculosis in our country, empirical antituberculous treatment with the Revised National Tuberculosis Control Programme CAT I regimen was started. Her colonic biopsy was reported as CMV colitis with typical appearance of cytomegalic cells and inclusion bodies in cytoplasm and nucleus [Figure 1]. No features of inflammatory bowel disease or tuberculosis were seen in biopsy from multiple sites.
Figure 1: Histopathology of colonic biopsy; arrow showing typical appearance of cytomegalic cells and inclusion bodies in cytoplasm and nucleus (H and E, ×40)

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Patient's general condition and bowel symptoms improved by the end of 1 st week of hospital stay, and hence, antiviral drugs were not started on receiving the colonic biopsy report in the 2 nd week. Review colonoscopy was done after 1 month which showed remarkable improvement in colonic ulcers.


  Discussion Top


It is uncommon to find clinically significant CMV-related disease among immunocompetent host. Most of the infections occur during childhood which suggests that subclinical or mild primary infections are common.

Our case shows severe systemic features of CMV infection such as ascites and pleural effusion. Exudative ascites is usually seen when there is transmural involvement of colon. CMV infection with systemic features is rarely seen in immunocompetent host.

In CMV infection, gastrointestinal tract is one of the most commonly affected systems, especially the colon. [6] The presence of underlying mucosal pathology such as inflammatory bowel disease has been reported to be a risk factor for CMV colitis. [7] Our patient did not have any underlying colonic disorder. Clinical manifestations of CMV colitis are similar to other infective causes, with diarrhea, fever, and abdominal pain predominating. In one study, 53% of the patients with diarrhea had bloody stools and another 20% had positive occult blood testing. [1]

CMV colitis has been described in different age groups, ranging from very young (5-week-old infant) to young adults [8] and the elderly. [9]

Studies have shown that CMV colitis in immunocompetent patients presented in older patients and in those with other comorbidities, [10] but our patient was found to have systemic features of CMV infection without any other comorbidities.

Since there is not much role for serology of CMV, we did not do serology for our patient. Only 38.6% had supporting serology in one of the meta-analyses of CMV colitis in immunocompetent hosts. [8]

CMV colitis is usually treated with intravenous ganciclovir or foscarnet for 2-4 weeks. Treating CMV colitis in an immunocompetent patient should be weighed against the potential toxicity of antiviral therapy. Treatment for CMV colitis is indicated only in severely ill patients taking into consideration self-limiting nature of disease and side effects of drugs used for treatment.

Our patient improved without any specific treatment for CMV colitis and the given antituberculous drugs have no reported antiviral effect. It is reported that approximately one-third of patients has recovered without any treatment for CMV infection. [7] A meta-analysis showed that spontaneous remission of CMV colitis occurred in 31.8%, mostly individuals < 55-year-old, [3] and our patient is also in this age group.

Our patient had myeloid leukemoid reaction with total leukocyte count going till 61,500/mm 3 . CMV colitis produces leukemoid reaction or leukocytosis in immunocompetent host while leukopenia is seen in immunosuppressed patients.

We would like to conclude that reactivation or primary CMV colitis should be considered even in an immunocompetent patient with diarrhea, abdominal pain, and other systemic features.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Friel TJ. Epidemiology, clinical manifestations, and treatments of cytomegalovirus infection in immunocompetent hosts. In: UpToDate; April, 2015. Available from: http://www.uptodate.[Last accessed on 2015 Apr 2].  Back to cited text no. 1
    
2.
Centers for Disease Control and Prevention. Department of Health and Human Services. Available from: http://www.cdc.gov/cmv/facts.htm. [Last accessed on 2015 Apr 2].  Back to cited text no. 2
    
3.
Galiatsatos P, Shrier I, Lamoureux E, Szilagyi A. Meta-analysis of outcome of cytomegalovirus colitis in immunocompetent hosts. Dig Dis Sci 2005;50:609-16.  Back to cited text no. 3
    
4.
Goodgame RW. Gastrointestinal cytomegalovirus disease. Ann Intern Med 1993;119:924-35.  Back to cited text no. 4
    
5.
Chetty R, Roskell DE. Cytomegalovirus infection in the gastrointestinal tract. J Clin Pathol 1994;47:968-72.  Back to cited text no. 5
    
6.
Rafailidis PI, Mourtzoukou EG, Varbobitis IC, Falagas ME. Severe cytomegalovirus infection in apparently immunocompetent patients: A systematic review. Virol J 2008;5:47.  Back to cited text no. 6
    
7.
Kandiel A, Lashner B. Cytomegalovirus colitis complicating inflammatory bowel disease. Am J Gastroenterol 2006;101:2857-65.  Back to cited text no. 7
    
8.
Blair SD, Forbes A, Parkins RA. CMV colitis in an immunocompetent adult. J R Soc Med 1992;85:238-9.  Back to cited text no. 8
    
9.
Lockwood MR, Liddle J, Kitsanta P. Cytomegalovirus colitis - An unusual cause for diarrhoea in an elderly woman. Age Ageing 2006;35:198-200.  Back to cited text no. 9
    
10.
Seo TH, Kim JH, Ko SY, Hong SN, Lee SY, Sung IK, et al. Cytomegalovirus colitis in immunocompetent patients: A clinical and endoscopic study. Hepatogastroenterology 2012;59:2137-41.  Back to cited text no. 10
    


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