Primary cytomegalovirus infection associated with the onset of ulcerative colitis

Cytomegalovirus enterocolitis with subsequent diagnosis of coexisting new-onset inflammatory bowel disease: Two case reports and review of the literature

INTRODUCTION

Gastrointestinal (GI) cytomegalovirus (CMV) infection coexisting with or followed by a diagnosis of inflammatory bowel disease (IBD) is infrequently reported. Not recognizing this condition may delay IBD diagnosis in patients with GI-CMV disease who do not or partially respond to antiviral agents, which could consequently result in unsatisfied treatment outcomes.

PATIENT CONCERNS

Two immunocompetent patients with no known underlying GI conditions presented with acute bloody diarrhea. The first patient developed diarrhea and hematochezia after admission to intensive care unit (ICU) because of severe alcoholic pancreatitis for 10 days duration. Computed tomography abdomen showed segmental jejunal thickening. The other patient presented with a 1-week history of severe bloody diarrhea which required ICU admission. Colonoscopy showed multiple ulcers along terminal ileum and colon.

DIAGNOSIS

These 2 patients were initially diagnosed with CMV jejunitis and ileocolitis, respectively, based on endoscopic and histopathologic findings. Both had partial response to treatment with 3 weeks of intravenous ganciclovir. Crohn disease was suspected because of persistent ulcerations on the follow-up endoscopy with the presence of pathological features of chronic inflammation and disappearance of previously detected CMV-infected cells.

INTERVENTION

Both patients were treated with systemic corticosteroids and azathioprine.

OUTCOMES

Both patients had complete clinical improvement. Prednisolone could be tapered off in 6 months. Follow-up video capsule endoscopy (VCE) at 6 months showed improvement of mucosal inflammation and ulcers, but neither were completely healed in the first patient. Follow-up colonoscopy at 6 months showed complete resolution of ulcers and inflammation in the second patient.

LESSONS

IBD should be suspected in patients with a diagnosis of GI-CMV disease who are immunocompetent and have a partial response to antiviral agents. This clinical scenario could be caused by either CMV infection activating immune response resulting in IBD onset, or CMV infection superimposed on pre-existing latent IBD.

Does lower gastrointestinal endoscopy during pregnancy pose a risk for mother and child? - a systematic review

BACKGROUND

Gastrointestinal endoscopy plays a crucial role in the diagnosis and management of gastrointestinal disorders. When endoscopy is indicated during pregnancy, concerns about the effects on pregnancy outcome often arise. The aim of this study was to assess whether lower gastrointestinal endoscopies (LGEs) across all three trimesters of pregnancy affects pregnancy outcomes.

METHODS

A systematic literature search was performed using Embase (including MEDLINE), Medline OvidSP, Cochrane Central Register of Controlled Trials, Web-of-Science, Google scholar and Pubmed. All original research articles from 1990 until May 2014 involving pregnant women who underwent LGE for any indication were included. Adverse pregnancy events like spontaneous abortion, preterm birth and fetal demise were assessed for a temporal and etiological relation with the LGE.

RESULTS

In total, 5514 references were screened by two independent reviewers. Eighty-two references met the inclusion criteria and were selected. Two retrospective, controlled studies, one uncontrolled study and 79 case reports were identified. In the three studies, birth outcomes did not differ between women undergoing LGE during pregnancy, compared to women that had an indication for LGE but in whom LGE was not performed because of pregnancy. In 79 case reports, 92 patients are described who underwent 100 LGE's during pregnancy. LGEs performed in all trimesters (n = 32, 39 and 29) were both temporally and etiologically related to 1, 3 and 2 adverse events, respectively.

CONCLUSION

Based on the available literature, this review concludes that lower gastrointestinal endoscopy during pregnancy is of low risk for mother and child in all three trimesters of pregnancy.

Looking for endoscopic features of cytomegalovirus colitis: a study of 187 patients with active ulcerative colitis, positive and negative for cytomegalovirus

BACKGROUND

Cytomegalovirus (CMV) is frequently detected in ulcerative colitis (UC) lesions of steroid-refractory patients. This has led to the suspicion that CMV might cause colitis and steroid refractoriness.

METHODS

During 2003 and 2011, 187 consecutive patients were divided into group I (n = 105), corticosteroid-free and thiopurine-free in the past 6 months, and group II (n = 82), all corticosteroid refractory. The combination of serum CMV immunoglobulin (Ig)M, CMV IgG, CMV antigenemia (Ag), and real-time polymerase chain reaction assays were performed to identify CMV(+) patients.

RESULTS

In group I, 79 patients were CMV IgG(+) and 26 patients were CMV IgG(-) and CMV IgM(-). In group II, 61 patients were CMV IgG(+), 1 CMV IgM(+), and 20 CMV IgG(-) and CMV IgM(-). All CMV IgG(+) patients were screened for CMV Ag. In group I, 6 of the 79 CMV IgG(+) patients were CMV Ag(+). In group II, 27 patients were CMV Ag(+). Colonoscopy was performed in all patients before screening for CMV. Similar colonoscopic features including punched out ulcers, geographic ulcers, and irregular ulcers were found in both CMV(+) and CMV(-) patients, without any striking difference between the 2 groups.

CONCLUSIONS

CMV reactivation might be encouraged by immunosuppressive drugs, like corticosteroids, immunomodulators, and therefore, patients with UC are at a high risk of CMV reactivation, potentially exacerbating UC. However, this study of 187 patients, CMV(+) and CMV(-), could not find colonoscopic features unique to CMV, except that CMV might be one factor for steroid refractoriness, and UC exacerbation.

Cytomegalovirus infection associated with onset of ulcerative colitis

Background

In 2009, a trigger role of cytomegalovirus (CMV) was shown in the development of ulcerative colitis (UC) in mice. Fifteen cases of synchronous onset of CMV colitis and UC have been reported in literature. A careful prospective and retrospective survey identified CMV colitis in newly diagnosed UC patients at 4.5% (3/65 cases) and 8.2% (5/61 cases), respectively. This means that a majority of synchronous CMV colitis may be missed in newly diagnosed UC patients in routine practice. Such a case is presented.

Case presentation

A 50-year-old woman, with a history of right partial mastectomy two years ago, had a persistent high fever for 9 days, after which a thickness of the colonic wall was detected on abdominal ultrasonography. Laboratory data showed inflammation and 2% atypical lymphocytes with the normal number of white blood cells. Although there was no bloody stool, fecal occult blood was over 1000 ng/ml. Colonoscopy showed diffuse inflammation in the entire large bowel and pseudomembranes in the sigmoid colon. The diagnosis was UC with antibiotic-associated pseudomembranous colitis. Metronidazole followed by sulfasalazine resulted in defervescence and improvement in laboratory data of inflammation. It took one month for normalization of fecal occult blood. Endoscopic remission was simultaneously confirmed. Later, it was found that a report of positive CMV antigenaemia (2/150,000) had been missed. Reevaluation of biopsy specimens using a monoclonal antibody against CMV identified positive cells, although inclusion bodies were not found in hematoxylin and eosin sections. Finally, the case was concluded to be synchronous onset of CMV colitis and UC.

Conclusion

Synchronous CMV colitis is not routinely investigated in newly diagnosed UC patients. Together with a recent observation in animal studies, it is plausible that a subset (a few to several per cent) of UC patients develop synchronous CMV infection. Further studies are needed to elucidate the plausibility.

How to manage IBD in patients with infections or malignancies?

Infections and malignancies are a major issue for clinicians in the management of patients with IBD because of concerns about the safety of drugs currently used in treatment, including immunosuppressive agents, steroids and tumor necrosis factor (TNF) antagonists. Infections are strongly associated with IBD both in their etiopathogenesis and in their clinical course. A number of viral infections, tuberculosis and other therapy-related infections create challenges for the successful management of intestinal disease with immunosuppressive agents or TNF antagonists. Recently published guidelines offer a strong support to deal with these issues. Major concern about IBD patients with malignancies is related to the consequences of chemotherapy on the intestinal disease, the risk of maintaining immunosuppressant or anti-TNF therapy after the diagnosis of malignancy and the management of a clinical relapse of IBD in patients with a recent diagnosis of malignancy. Further research is required to optimize strategies for IBD patients with malignancies. At the moment, all therapeutic choice is made on an individual basis, with an integrative multidisciplinary approach.

Cytomegalovirus enteritis causing ileal perforation in an elderly immunocompetent individual

Cytomegalovirus (CMV) infection is usually subclinical in immunocompetent individuals, however it can be life threatening in an elderly immunocompetent individual. We report a case of CMV enteritis causing ileal perforation in a physically active elderly man. An 88-year-old healthy man presented with abdominal pain and diarrhea. After initial conservative treatment, emergency laparotomy was performed for ileal perforation. The diagnosis of CMV enteritis was based on histological findings revealing many large cells with CMV inclusion bodies in the surgical specimen. In elderly individuals, even though they are immunocompetent, CMV enteritis may result in major complications such as bowel perforation, and it should be included in the differential diagnosis of diarrhea if it is resistant to conventional treatment.

Possible role of human cytomegalovirus in pouchitis after proctocolectomy with ileal pouch-anal anastomosis in patients with ulcerative colitis

AIM: To detect the presence of human cytomegalovirus (HCMV) proteins and genes on the ileal pouch of patients with ulcerative colitis who have undergone proctocolectomy with ileal pouch-anal anastomosis (IPAA).

METHODS: Immunohistochemistry, polymerase chain reaction (PCR) and PCR sequencing methods were utilized to test the presence of HCMV in pouch specimens taken from 34 patients in 86 endoscopies.

RESULTS: HCMV genes and proteins were detected in samples from 12 (35.2%) patients. The rate of detection was significant in the endoscopies from patients diagnosed with pouchitis (5 of 12, 41.6%), according to the Japanese classification of pouchitis, in comparison to patients with normal pouch (7 of 62, 11.2%; P = 0.021). In all patients with pouchitis in which the HCMV was detected, it was the first episode of pouchitis. The virus was not detected in previous biopsies taken in normal endoscopies of these patients. During the follow-up, HCMV was detected in one patient with recurrent pouchitis and in 3 patients whose pouchitis episodes improved but whose positive endoscopic findings persisted.

CONCLUSION: HCMV can take part in the inflammatory process of the pouch in some patients with ulcerative colitis who have undergone proctocolectomy with IPAA.

Frequent detection of cytomegalovirus in the intestine of patients with inflammatory bowel disease

BACKGROUND

Although a growing number of reports have described inflammatory bowel disease (IBD) complicated with cytomegalovirus (CMV) infection, there are limited molecular studies that investigate CMV genome in intestinal sections of patients with IBD.

METHODS

A cross-sectional prospective study was conducted between September 2000 and June 2003 in a cohort of 85 patients diagnosed with IBD (58 with ulcerative colitis and 27 with Crohn's disease) in two adult gastrointestinal referral centers in Athens, Greece. Prevalence of CMV infection was estimated by pathologic studies in intestinal sections and by molecular assays in blood and intestinal tissue samples and compared with a control group of 42 individuals with noninflammatory disease.

RESULTS

Immunohistochemical staining showed CMV antigen in 10 IBD patients (7 with ulcerative colitis; 9 with severe disease), whereas CMV antigen was not detected in any of the controls. CMV genome in both the intestinal tissue and blood was found by polymerase chain reaction in 23 (27.1%) of the total IBD patients, in 18 (31.0%) of those with ulcerative colitis, and in 5 (18.5%) of those with Crohn's disease. In addition, five (5.9%) IBD patients (2 with ulcerative colitis and 3 with Crohn's disease) had detectable CMV genome in their intestinal samples but not in their blood. In the control group, five (11.9%) individuals had detectable CMV genome in their blood, but only one (2.2%) in his intestine.

CONCLUSION

Patients with ulcerative colitis had more often detectable CMV genome in their blood as well as in their intestinal tissue samples as compared with controls (P = 0.022 and P < 0.0001, respectively). However, patients with Crohn's disease had more often detectable CMV genome only in their intestinal tissue samples as compared with controls (P = 0.001). Detection of CMV genome in blood or intestinal tissue was significantly associated with short duration of IBD (P = 0.0088 and 0.04, respectively) but not with age, sex, severity of the disease, activity at colonoscopy, pancolitis, administration of a specific treatment, and surgery. In this cross-sectional prospective study, detection of CMV genome or antigen in the intestine was commonly associated with IBD.

[Cecal cytomegalovirus infection following appendicectomy in a patient with ulcerative colitis]

We report a patient who, 3 months after being diagnosed with ulcerative colitis, was admitted to hospital because of malaise and right lower abdominal pain. An open appendectomy was performed. Histological study showed ulcerative colitis affecting the appendix. After surgery, the patient presented a refractory outbreak of ulcerative colitis requiring treatment with steroids and cyclosporin A. Despite this treatment, the patient continued to pass abundant fresh blood associated with severe anemia. Colonoscopy showed only granular and congestive cecal mucosa. Biopsies showed intracytoplasmic inclusion bodies with immunohistochemical stains positive for cytomegalovirus (CMV) infection. Rectorrhagia and anemia quickly disappeared after beginning treatment with ganciclovir. Appendicular ulcerative colitis is not uncommonly associated with distal colitis. In addition, diffuse CMV infection complicating ulcerative colitis treatment is not unusual. By contrast, isolated, segmentary infection by CMV in the proximal colon is extremely rare. Until now, only three patients with localized CMV infection have been described, and all three cases occurred in the context of ileoanal anastomosis.

Meta-analysis of outcome of cytomegalovirus colitis in immunocompetent hosts

There are only a few anecdotal reports of cytomegalovirus (CMV) colitis in immunocompetent hosts. The impact of the disease in this patient population remains poorly understood. The aim of this study was to perform a meta-analysis using individual patient data to determine outcomes of CMV colitis in immunocompetent patients and identify risk factors that might influence prognosis. A literature search was performed from 1980 to 2003 looking for immunocompetent patients with CMV colitis. Immunocompetence was defined as absence of congenital or acquired immune deficiency, transplant, or immunosuppressive medication. Patients were divided by age (<55 versus > or =55) and grouped according to coexisting illnesses. Kaplan-Meier curves were plotted to assess survival. Variables included age, sex, site of acquisition of infection, extent of disease, coexisting illnesses, and treatment modality. A total of 44 patients were identified, with an average age of 61.1. Only 10 were free of any comorbidity. The mean follow-up was 13.4 months. Spontaneous remission occurred in 31.8%, mostly individuals <55 years old. Fourteen deaths occurred, all of which were in patients >55. There was a higher mortality rate among male patients > or =55 (56.9%; P = 0.08), patients with immune-modulating diseases (75.2%; P = 0.10), and those having a colectomy (68.9%; P = 0.09). This analysis underlines the rarity of CMV colitis in patients with an intact immune system. Advanced age, male gender, presence of immune-modulating comorbidities, and need for surgical intervention are factors negatively influencing survival. Conversely, young healthy patients have a good prognosis with no intervention.

Infection with cytomegalovirus in patients with inflammatory bowel disease: prevalence, clinical significance and outcome

Despite frequent use of immunosuppressive drugs in patients with inflammatory bowel disease (IBD) and reports of cytomegalovirus (CMV) infection following post-transplant immunosuppression, data on the frequency and clinical significance of CMV in patients with IBD are scant. Sixty-three patients with IBD (61 ulcerative colitis and two Crohn's disease) were evaluated for CMV using serology (IgM antibody, μ-capture ELISA), PCR for CMV DNA in colonic biopsy and histological assessment of haematoxylin and eosin-stained colonic biopsy. Positive result in any test was considered as CMV infection. Various parameters associated with CMV infection were analysed using univariate and multivariate analysis. Ten of 63 (15.8 %) patients (age 36.0 ± 11.2 years, 31 female) were infected with CMV (DNA alone in four, IgM antibody alone in two and both in four, inclusion body in one). Patients with CMV infection were more often female (8/10 vs 23/53,P< 0.05), had pancolitis (10/10 vs 33/53,P< 0.05), histological activity (9/10 vs 17/53,P< 0.005) and used azathioprine (5/10 vs 7/53,P= 0.04; Fisher exact test for all). On multivariate analysis, female gender, pancolitis and histological activity were the independent factors associated with infection. Patients with CMV infection more often required surgical treatment for IBD (4/10 vs 4/53,P= 0.01) and had fatal outcome (3/10 vs 0/53,P= 0.003). CMV infection in patients with IBD may be common and is associated with poor outcome. PCR of rectal biopsy was the most sensitive method of detection followed by IgM antibody for diagnosis.

Cytomegalovirus infection in steroid-refractory ulcerative colitis: a case-control study

Cytomegalovirus (CMV) infection is reported to be a cause of steroid-refractory ulcerative colitis (UC), but the strength of this association has not been tested in a case control study. Controlled studies have also not been performed to determine the sensitivity of available immunohistochemical techniques to detect CMV in this setting. The pathology database at Stanford Hospital was searched for UC patients with a diagnosis of "severe colitis" between the years 1992 and 2002 and medical records were reviewed. Forty patients were identified with refractory UC, defined as poor response to highdose systemic steroids for >2 weeks. Another group of 40 patients with severe, but nonrefractory, UC was case-matched for age and year of biopsy. A series of 40 patients who underwent colectomy for reasons other than inflammatory bowel disease with representative sections of "normal" colon were selected as noncolitis controls. CMV inclusions were detected on hematoxylin and eosin (H&E) in 2 of 40 patients with refractory UC, but not in other patients. Immunohistochemistry (IHC) detected CMV in 10 of 40 (25%) patients with refractory UC and 1 of 40 (2.5%) patients with nonrefractory UC (P = 0.007). The CMV-positive cases initially identified on IHC but not on H&E were re-reviewed for viral inclusions on H&E: 3 had rare, but typical, inclusions; 3 had atypical inclusions; and 3 had no inclusions. CMV was not detected by H&E or IHC in 40 noncolitis controls. Of 10 steroid-refractory UC patients with CMV detected, 7 were refractory to cyclosporin or 6-mercaptopurine/azathioprine (70%) and 6 had undergone proctocolectomy (60%) prior to detection of the CMV. Two patients with recognized CMV infection were treated with gancyclovir, improved, and were able to taper off steroids and avoid proctocolectomy. This study provides evidence that unrecognized and therefore untreated CMV infection is significantly associated with steroid-refractory UC. Moreover, IHC is more sensitive than H&E for detection of CMV and should be considered as part of the routine evaluation of steroid-refractory UC patients, before proceeding with other medical or surgical therapy that may be unnecessary once the CMV is treated.

Self-limited colitis during the course of rubella and cytomegalovirus infection in an immunocompetent adult

We report a case of self-limited colitis in cytomegalovirus (CMV) infection in an immunocompetent adult. A 22-year-old man developed a high fever and diarrhea. Laboratory data revealed an increased number of lymphocytes and liver damage. Enzyme immunoassays for anti-virus antibodies revealed that the patient was recently infected with CMV and rubella. Colonoscopy revealed severe erosive and edematous mucosa that resembled ulcerative colitis (UC). The symptoms, laboratory data and colonoscopic findings improved without any medical treatment. This case indicates that UC-like self-limited colitis can occur in an immunocompetent individual during the course of CMV infection.

The pathogenicity of cytomegalovirus in inflammatory bowel disease: a systematic review and evidence-based recommendations for future research

During recent years, a clear association between complicated courses of ulcerative colitis and the presence of cytomegalovirus (CMV) has been established. The exact pathogenic role of CMV in these patients remains unclear despite a great number of published reports. Therefore, we undertook a systematic review to appraise critically all available evidence in the literature on the role of CMV during inflammatory bowel disease. We identified and analyzed more than 30 case reports and 9 case series. Based on these results, we propose a model for viral replication during inflammation and provide recommendations for future research.

[Acute cytomegalovirus (CMV) recto-colitis mimicking rectal carcinoma without apparent cause of immunodeficiency]

Cytomegalovirus (CMV) infection of the gastrointestinal tract occurs mainly in immunosuppressed patients. We report here the case of a 76-Year-old woman, without obvious cause of immunosuppression, who developed severe proctitis. The clinical course was favourable with ganciclovir therapy. In the absence of controlled data in the field of CMV intestinal infections in immunocompetents, we discuss the potential benefit of an antiviral therapy in those patients who do not recover rapidly and spontaneously.

Kaposi's sarcoma and cytomegaloviral ileocolitis complicating long-standing Crohn's disease in an HIV-negative patient

A 67-yr-old woman with a 25-yr history of Crohn's disease, maintained on near-continuous corticosteroids (prednisone 10 mg daily) over a 6-yr period, underwent ileocolic resection for obstruction. Pathology revealed Crohn's disease, multiple nodules of Kaposi's sarcoma, and cytomegalic inclusion bodies with confirmation of cytomegalovirus by shell vial immunofluorescence. Testing for HIV serum antibody has been repeatedly negative. Crohn's disease, Kaposi's sarcoma, and cytomegalovirus have been clinically in remission for 5 yr.

Outcome of cytomegalovirus infections in patients with inflammatory bowel disease

OBJECTIVE

The aim of this study was to determine the outcome of cytomegalovirus (CMV) infections complicating the course of inflammatory bowel disease (IBD).

METHODS

The records and clinical courses were reviewed for all IBD patients who were evaluated at the IBD Center of the Cedars-Sinai Medical Center and who developed CMV infection.

RESULTS

Ten patients with severe, medically refractory IBD (five ulcerative colitis, three Crohn's colitis, and two indeterminate colitis) developed CMV infection. All but two were hospitalized with exacerbation of their underlying disease and were receiving immunosuppressive treatment with steroids, thiopurines, and/or cyclosporine at the time CMV infection was recognized. Eight patients had documented colonic CMV (one had concurrent upper GI tract involvement), one developed interstitial CMV and Pneumocystis carinii pneumonia, and one developed primary CMV mononucleosis. Prompt treatment with ganciclovir and withdrawal of immunosuppressive treatment resulted in gradual improvement and induction of remission of the underlying IBD in five patients. The patient with concomitant CMV and P. carinii pneumonitis died. In two patients, treatment with ganciclovir did not alter the clinical course of their IBD, and one of them underwent colectomy. In one patient CMV was found on the resected colonic specimen. One patient with primary CMV infection responded also to ganciclovir treatment.

CONCLUSIONS

CMV infection may aggravate the course of seemingly refractory IBD in patients who either fail to respond or experience worsening of symptoms despite immunosuppressive therapy. Expedient evaluation, prompt treatment intervention with ganciclovir, and withdrawal of immunosuppressive treatment may avoid complications and mortality. This regimen leads to improvement of the underlying IBD in most patients.

Cytomegalovirus colitis complicating ulcerative colitis in the steroid-naive patient

We report a case of cytomegalovirus (CMV) presenting as acute refractory colitis in a patient with a pre-existing 14-month history of ulcerative colitis (UC) who had never previously been treated with corticosteroids or immunosuppressants. A review of existing literature and previous cases of patients with coincident CMV and UC are examined, stratifying these cases based upon absence or presence of corticosteroid use. To date, only five previous case reports of CMV colitis in patients naive to corticosteroids have been described, and only one previous case has had UC diagnosed over 4 wk before the development of CMV colitis. We further discuss the relationship between these two diseases as well as the diagnosis, treatment, patient characteristics, and outcome of CMV infection of the colon in patients with underlying UC. We discuss the need to consider the diagnosis of CMV colitis in patients with refractory UC who are not receiving corticosteroid treatment as well as those who are refractory and are being treated with immunosuppressants and/or corticosteroids.

Cytomegalovirus infection in patients with inflammatory bowel disease

OBJECTIVE

It has been suggested that, in inflammatory bowel disease, cytomegalovirus behaves in the intestine as a nonpathogenic bystander, and even its finding in intestinal mucosa has unclear clinical relevance. We report our experience with a small series of patients with refractory inflammatory bowel disease and cytomegalovirus infection and their clinical outcome.

METHODS AND RESULTS

Nine patients with moderate-severe attacks of inflammatory bowel disease did not respond to i.v. prednisone (1 mg/kg/day) for a mean of 24 days. Four of these patients were further treated with i.v. cyclosporine A (4 mg/kg/day). Cytomegalovirus infection was diagnosed in two patients after resection for treatment failure. In the remaining patients, cytomegalovirus infection was diagnosed in endoscopic mucosal biopsies and i.v. ganciclovir was then administered at a dose of 10 mg/kg/day for 2-3 wk. Five of these patients went into clinical remission, allowing corticosteroid and cyclosporine A discontinuation. Follow-up biopsies were performed and in all cases cytomegalovirus could not be detected in the colonic tissue. Two patients needed to be treated with intravenous cyclosporine A after antiviral therapy because of persistence of clinical symptoms despite the elimination of cytomegalovirus infection.

CONCLUSIONS

Cytomegalovirus infection may play a role in the natural history of refractory inflammatory bowel disease and in some of its complications. The clearance of cytomegalovirus in colonic mucosa may lead some of these patients to remission.

Pouchitis associated with primary cytomegalovirus infection

We report a patient with a history of ulcerative colitis status after total proctocolectomy with an ileoanal J pouch who presented with marked, refractory pouchitis associated with a primary cytomegalovirus (CMV) infection. The patient had atypical lymphocytosis in the blood and serology consistent with primary CMV infection. Biopsies of the pouch revealed CMV inclusion bodies and yielded positive CMV cultures. The patient improved clinically with resolution of pouchitis after a 10-day course of therapy with gancyclovir and has remained in remission for over 5 yr. This is the first report of pouchitis associated with a primary CMV infection. This case demonstrates that CMV infection is in the differential diagnosis for causes of pouchitis, and it suggests that the pouch, like the colon, is a potential site for a primary CMV infection in an immunocompetent host.

Cytomegalic colitis after total colectomy in ulcerative colitis: report of a case

A 58-year-old man with ulcerative colitis underwent total colectomy and ileorectal anastomosis. Steroid suppositories were administered postoperatively, and he had had no exacerbation in the residual rectum for 12 years. He suddenly presented with frequent bloody stools and anal pain. An intensive intravenous regimen of prednisolone was ineffective. Cytomegalic inclusion bodies were identified in biopsy specimens. Administration of ganciclovir reduced the ulcers remarkably. The clinical course suggested that this deterioration was caused by cytomegalovirus infection from the beginning. Cytomegalovirus colitis should be recognized as an exacerbating factor, even in ulcerative colitis patients who have undergone surgery, especially when the residual bowel inflammation is resistant to steroid therapy.