Cytomegalovirus colitis in individuals without apparent cause of immunodeficiency

Cytomegalovirus Diseases of the Gastrointestinal Tract in Immunocompetent Patients: A Narrative Review

Cytomegalovirus (CMV) is a potential pathogen that causes gastrointestinal (GI) tract diseases regardless of host immunity. In contrast to immunocompromised individuals, immunocompetent patients lack a comprehensive overview of the gastrointestinal manifestations. This study aims to provide a comprehensive summary of the current evidence regarding presentations, diagnostics, management, risk assessment, and outcomes in immunocompetent patients with CMV GI disease. A thorough literature search of English publications up to April 2022 was conducted across electronic databases to identify relevant articles, with eligible case series selected for detailed analysis. The majority of immunocompetent patients affected by CMV GI disease are typically elderly, critically ill, or burdened with comorbidities that compromise immunity. Clinical presentations range from subtle symptoms to severe surgical conditions, including instances of mortality. Specific clinical presentations, blood test results, or endoscopic features are lacking, necessitating reliance on histopathological tests such as immunohistochemistry staining for diagnosis. While antiviral therapy may offer benefits in improving outcomes, careful individual assessment is warranted due to diverse comorbidities and potential side effects. Mortality rates vary considerably based on underlying medical conditions and therapeutic approaches. It is imperative for clinicians to maintain vigilance for CMV GI disease among high-risk groups, despite their baseline immunocompetence, in order to enhance clinical outcomes.

Cytomegalovirus Proctitis Developed after COVID-19 Vaccine: A Case Report and Literature Review

(1) Background: We describe a case of a 58-year-old Chinese woman, without obvious cause of immunosuppression, who developed cytomegalovirus (CMV) proctitis three days after a second COVID-19 vaccination. Electronic colonoscopy revealed a new lesion that was circumferential at the anorectal junction, with an uneven surface and ulceration, which mimicked rectal carcinoma. This is the first case of CMV proctitis following vaccination since the invention of the COVID-19 vaccine, suggesting that the COVID-19 vaccine may cause disorders of immune homeostasis, including not only immune hyperactivity but also immune deficiency. We report this case to increase readers’ awareness of the risks after COVID-19 vaccination and to provide new ideas for the diagnosis and treatment of similar cases. (2) Methods: In this case, we used laboratory biochemical examinations, colonoscopy, immunohistochemistry, and a biochemical index to confirm the existence of CMV proctitis. (3) Results: In this case, the vaccine-induced CMV proctitis had a similar endoscopic appearance to rectal neoplastic lesions, which could be confirmed by biopsy and quickly relieved by ganciclovir treatment. Ganciclovir was used to treat the patient, and a good effect was observed. (4) Conclusions: COVID-19 vaccination may cause immune disorders, not just immune hyperactivity as previously reported, but also immune deficiency, such as CMV proctitis in this case. The clinical course of CMV proctitis secondary to COVID-19 vaccination was favorable with ganciclovir therapy.

Clinical Features, Endoscopic Findings, and Predictive Factors for Mortality in Tissue-Invasive Gastrointestinal Cytomegalovirus Disease between Immunocompetent and Immunocompromised Patients

Background and Aims

Tissue-invasive gastrointestinal cytomegalovirus (TI-GI CMV) disease is common in immunocompromised patients, but the increasing prevalence in immunocompetent patients has been reported. This study compared the clinical manifestations, endoscopic features, treatment outcomes, and predictors for inhospital mortality of TI-GI CMV between immunocompromised and immunocompetent patients.

Methods

Patients with HIV infection, malignancy, or receiving immunosuppressive agents (chemotherapy, high dose, or long-term corticosteroids) were defined as the immunocompromised group. Demographic and inhospital mortality data were obtained and retrospectively analyzed.

Results

A total of 213 patients (89 immunocompetent) with histologically confirmed TI-GI CMV were enrolled. Immunocompetent patients were older (70 vs. 52 years; p < 0.001), had more GI bleeding as a presenting symptom (47.2% vs. 29.0%; p = 0.010), and shorter symptom onset (2 vs. 14 days, p = 0.018). Concomitant extra-GI involvement was only seen in the immunocompromised group (6.5% vs. 0%; p = 0.02). Diffuse GI tract (14.5% vs. 4.5%; p = 0.032) and esophageal involvement (14.5% vs. 5.6%; p = 0.046) were more frequent in the immunocompromised, while small bowel involvement was more frequent in the immunocompetent group (19.1% vs. 8.1%; p = 0.029). An overall inhospital mortality was 27.7%. There was no significant difference in inhospital survival probability between the two groups (Peto-Peto test, p = 0.65). ICU admission (hazard ratio [HR] 7.21; 95% CI 2.55-20.36), sepsis or shock (HR 1.98; 95% CI 1.08-3.66), malnutrition (HR 2.62; 95% CI 1.05-7.01), and receiving chemotherapy (HR 5.2; 95% CI 1.89-14.29) were independent factors for inhospital mortality. Antiviral treatment for more than 14 days was the only protective factor to improve survival (Peto-Peto test, p < 0.001).

Conclusions

Immunocompetent and immunocompromised patients with TI-GI CMV disease had distinct clinical and endoscopic characteristics. There was no significant difference in the inhospital mortality between the two groups. The factors for mortality were ICU admission, sepsis/shock, malnutrition, and receiving chemotherapy. Early diagnosis and initiation of antiviral treatment might improve the survival probability.

Patient characteristics, clinical manifestations, prognosis, and factors associated with gastrointestinal cytomegalovirus infection in immunocompetent patients

Background

Gastrointestinal (GI) cytomegaloviral (CMV) infection is common among patients with immunocompromised status; however, data specific to GI-CMV infection in immunocompetent patients are comparatively limited.

Methods

This retrospective study included patients diagnosed with GI-CMV infection at Siriraj Hospital (Bangkok, Thailand) during 2008–2017. Baseline characteristics, presentations, comorbid conditions, endoscopic findings, treatments, and outcomes were compared between immunocompetent and immunocompromised.

Results

One hundred and seventy-three patients (56 immunocompetent, 117 immunocompromised) were included. Immunocompetent patients were significantly older than immunocompromised patients (73 vs. 48.6 years, p < 0.0001). Significantly more immunocompetent patients were in the ICU at the time of diagnosis (21.0% vs. 8.6%, p = 0.024). GI bleeding was the leading presentation in immunocompetent, while diarrhea and abdominal pain were more common in immunocompromised. Blood CMV viral load was negative in significantly more immunocompetent than immunocompromised (40.7% vs. 12.9%, p = 0.002). Ganciclovir was the main treatment in both groups. Significantly more immunocompetent than immunocompromised did not receive any specific therapy (25.5% vs. 4.4%, p ≤ 0.01). Six-month mortality was significantly higher among immunocompetent patients (39.0% vs. 22.0%, p = 0.047). Independent predictors of death were old age and inpatient or ICU clinical setting. Treatment with antiviral agents was the only independent protective factor.

Conclusion

GI-CMV infection was frequently observed among immunocompetent elderly patients with comorbidities or severe concomitant illnesses. GI bleeding was the most common presentation. Blood CMV viral load was not diagnostically helpful. Significantly higher mortality was observed in immunocompetent than in immunocompromised patients, but this could be due to more severe concomitant illnesses in the immunocompetent group.

Cytomegalovirus induced refractory TTP in an immunocompetent individual: a case report

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) is a rare, potentially fatal disease with multisystem involvement. Cytomegalovirus (CMV) infection as a cause of refractory TTP, has been reported only in immunocompromised individuals. We report a case of CMV-induced refractory TTP in an immunocompetent individual.

CASE PRESENTATION

A 35-year-old, previously healthy Sri Lankan man, presented with fever for 3 days with gum bleeding and progressive drowsiness. His Glasgow coma scale score was 10/15. He did not have papilloedema or neck stiffness. Laboratory evaluation showed a severe thrombocytopenia with microangiopathic haemolytic anaemia. There was marginal renal impairment and normal coagulation profile. Non-contrast CT scan of brain was normal. A diagnosis of thrombotic thrombocytopenic purpura was made. Despite daily plasma exchanges and high-dose steroids, he failed to achieve the expected therapeutic response, thus demonstrating refractory TTP. On exploring for possible causes of refractoriness to treatment, a clinically significant PCR titre of CMV was detected. Treatment of CMV infection lead to complete recovery of TTP. His disease course was further complicated with spontaneous spinal haemorrhage leading to neurological sequelae.

DISCUSSION AND CONCLUSIONS

This is the first report of CMV induced refractory TTP in an immunocompetent adult. It is also the first report of clinically significant spontaneous spinal haematoma in TTP. These two rare occurrences should be considered when patients with refractory TTP do not improve as expected.

Reactivated cytomegalovirus proctitis in an immunocompetent patient presenting as nosocomial diarrhea: a case report and literature review

BACKGROUND

Reactivated cytomegalovirus (CMV) infection has been known to cause significant morbidity and mortality in immunocompromised patients. However, CMV disease rarely develops in immunocompetent patients, and reported cases often present with a mild, self-limiting course, without severe life-threatening sequelae. While the colon is the most common gastrointestinal site affected by CMV disease in immunocompetent patients, rectal involvement is rarely reported. CMV proctitis can present in two distinct forms, primary and reactivated. However, reactivated CMV proctitis is rarely reported as a causative etiology of nosocomial diarrhea, except in transplant patients. Herein we present a case of reactivated CMV proctitis in an immunocompetent patient, presenting as nosocomial diarrhea. Previously reported cases of reactivated CMV proctitis in immunocompetent patients are also reviewed.

CASE PRESENTATION

A 79-year-old female was admitted because of metabolic encephalopathy caused by dehydration and hypernatremia. The patient's consciousness level returned rapidly after fluid supplementation. However, she subsequently presented with abdominal pain and diarrhea on day 8 of admission. Abdominal contrast-enhanced computed tomography on day 10 of admission demonstrated inflammation around the rectum, suggesting proctitis. Colonoscopy on day 16 of admission showed a giant ulcer at the rectum. Pathology of rectal biopsy confirmed CMV infection. The patient recovered without sequelae after 38 days of valganciclovir treatment. Follow-up colonoscopy revealed a healed ulcer over the rectum. Ten cases in the literature, plus our case, with reactivated CMV proctitis in immunocompetent patients were reviewed. We found that most patients were elderly (mean, 72 years) with a high prevalence of diabetes mellitus (54.5%). Cardinal manifestations are often non-specific (diarrhea, hematochezia, tenesmus), and eight (72.7%) developed CMV proctitis following a preceding acute, life-threatening disease, rather than as an initial presentation on admission. These manifestations frequently develop during hospitalization, and are thus often regarded as nosocomial diarrhea.

CONCLUSIONS

Clinicians should be aware of the possibility of nosocomial onset of reactivated CMV proctitis in patients hospitalized due to a preceding critical illness, although the benefits of antiviral therapy remain unclear.

Cytomegalovirus colitis mimicking rectal carcinoma in an immunocompetent elderly woman

Cytomegalovirus (CMV) colitis is uncommon in immunocompetent patients, despite a high seroprevalence rate of CMV in the general population. CMV infection has been described in individuals with compromised immune systems: in AIDS, under corticosteroid and immune modulating treatment, with cancer or haematological malignancies. Its most frequent clinical presentation is a necrotising ulcerative form; pseudotumoural CMV colitis has been described as highly exceptional. We report a case of CMV colitis mimicking rectal carcinoma in an immunocompetent elderly woman. The immunosenescence and protein-energy malnutrition increase incidence and severity of infectious diseases in elderly individuals. Immunosenescence may affect all aspects of immunity; severe protein malnutrition modifies mostly cellular immunity, growing susceptibility to infections.

Symptomatic cytomegalovirus gastrointestinal infection with positive quantitative real-time PCR findings in apparently immunocompetent patients: a case series

Cytomegalovirus (CMV) gastrointestinal disease rarely occurs in immunocompetent patients, and is mainly diagnosed on the basis of histopathological findings. Real-time PCR for CMV DNA quantification is considered to be a useful diagnostic tool, but its place in the diagnostic strategy is not clearly defined. The goal of the study was to describe the clinical and paraclinical features of apparently immunocompetent patients with CMV gastrointestinal disease diagnosed according to quantitative PCR results. In this retrospective study conducted in a 1500-bed tertiary-care centre, we reviewed the case records of apparently immunocompetent patients with positive findings of CMV DNA in gastrointestinal biopsies with compatible symptoms and endoscopic findings. A total of 13 patients were included between January 2007 and December 2010. The median age was 81 years, and 54% of patients had underlying immune-modulating conditions. Diarrhoea, haematochezia and dysphagia were the main reported symptoms, and ulcers were the main endoscopic findings. The mean value of CMV DNA load in gastrointestinal biopsies was 3845 copies/μg total DNA (range, 15-15 500 copies/μg total DNA). The highest values were found in two patients who were diagnosed with adenocarcinoma in the subsequent course of CMV infection. Clinical features were similar to those in previous series in which diagnosis was based on histopathological analysis. Elderly people are more commonly affected, and a link with immune senescence is possible. Quantification of CMV DNA seems to be a useful tool for diagnosis when combined with clinical and endoscopic findings, but further studies are necessary to interpret quantitative values.

[A case of hypopharyngeal ulceration due to cytomegarovirus infection]

Cytomegalovirus (CMV) is a common opportunistic infection in immunosuppressive patients. One of the organs often involved is the gastrointestinal tract, but the pharynx, especially hypopharyngeal involvement, is rare. In this report, we present a case of a 61-year-old male compromised host, admitted to the hospital for the treatment of dermatomyositis, who presented with hypopharyngeal ulceration due to cytomegalovirus infection. Multiple deep ulcerative lesions with thick belaque, or with a protruding bony edge were observed in the adjacent areas in/around the hypopharynx, which repeatedly demonstrated exacerbation and remission in a relatively short period. The lesions developed acute bleeding and required emergency operative hemostasis. The ulcerations completely disappeared after the treatment with gancyclovir. We reviewed our case as well as other cases reported so far, and extracted the points we should be aware of when we encounter a case of hypopharyngeal ulceration based on cytomegalovirus infection; 1. acute bleeding, 2. paralysis of the vocal cords and subsequent breathing difficulty, 3. pharyngeal perforation.

Clinical presentation and risk factors for cytomegalovirus colitis in immunocompetent adult patients

BACKGROUND

Cytomegalovirus (CMV) colitis is a common manifestation of CMV end-organ disease, which has typically been described in immunocompromised hosts. Recently, it has been noted that this also occurs in immunocompetent patients. To gather relevant data about clinical presentation, prognosis, and risk factors for development of CMV colitis in immunocompetent hosts, we analyzed all cases that occurred during a 19-year period at our institution.

METHODS

A case-control study was performed to identify risk factors for CMV colitis in immunocompetent hosts. Electronic medical records of individuals who were admitted and diagnosed with CMV colitis between January 1995 and February 2014 at a tertiary care university hospital were reviewed. Two non-CMV colitis patients who were age- and sex-matched were selected as controls for each case.

RESULTS

A total of 51 patients with CMV colitis were included in this study along with 102 control patients. Certain conditions including renal disease on hemodialysis, neurologic disease, rheumatologic disease, intensive care unit admission, and exposure to antibiotics, antacids, steroids, or red blood cell (RBC) transfusions within 1 month of diagnosis of colitis were associated with CMV colitis on univariate analysis. Among these, steroid use and RBC transfusion within 1 month were identified as independent risk factors for developing CMV colitis on multivariate analysis. The 30-day mortality rate was 7.8% without any attributable mortality.

CONCLUSIONS

Steroid use and RBC transfusion within 1 month of the diagnosis of colitis were independent risk factors for development of CMV colitis in immunocompetent hosts.

Cytomegalovirus proctitis: a rare and disregarded sexually transmitted disease

A review of published cases and a recently managed patient is presented, which describes the clinical features of cytomegalovirus proctitis. About half of the reports describe sexually transmitted cytomegalovirus proctitis following anal intercourse, which typically presents with rectal bleeding and a mononucleosis-like syndrome. This condition resolves spontaneously and may be associated with human immunodeficiency virus infection.

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.

Clinical significance of cytomegalovirus infection in patients with inflammatory bowel disease

Cytomegalovirus (CMV) infection is common in humans. The virus then enters a “latency phase” and can reactivate to different stimuli such as immunosuppression. The clinical significance of CMV infection in inflammatory bowel disease is different in Crohn’s disease (CD) and ulcerative colitis (UC). CMV does not interfere in the clinical course of CD. However, CMV reactivation is frequent in severe or steroid-resistant UC. It is not known whether the virus exacerbates the disease or simply appears as a bystander of a severe disease. Different methods are used to diagnose CMV colitis. Diagnosis is classically based on histopathological identification of viral-infected cells or CMV antigens in biopsied tissues using haematoxylin-eosin or immunohistochemistry, other tests on blood or tissue samples are currently being investigated. Polymerase chain reaction performed in colonic mucosa has a high sensitivity and a positive result could be associated with a worse prognosis disease; further studies are needed to determine the most appropriate strategy with positive CMV-DNA in colonic mucosa. Specific endoscopic features have not been described in active UC and CMV infection. CMV colitis is usually treated with ganciclovir for several weeks, there are different opinions about whether or not to stop immunosuppressive therapy. Other antiviral drugs may be used. Multicenter controlled studies would needed to determine which subgroup of UC patients would benefit from early antiviral treatment.

Concomitant Clostridium difficile colitis and cytomegalovirus colitis in an immunocompetent elderly female

A 78-year-old Japanese woman with diarrhoea and abdominal pain was admitted for PCR test (PCR)-proven Clostridium difficile colitis. The patient's symptoms persisted despite multiple courses of antibiotics including intravenous metronidazole, oral  vancomycin and oral fidaxomicin. She underwent a stool transplant without improvement. Biopsies from a colonoscopy revealed concomitant cytomegalovirus (CMV) infection. The patient was immediately started on intravenous ganciclovir. Unfortunately, she developed sepsis secondary to colitis, and underwent definitive treatment with a total colectomy. Although CMV is a rare colonic pathogen in the immunocompetent patient, it should be considered in patients with severe or refractory C difficile colitis.

Cytomegalovirus infection and the gastrointestinal tract

Cytomegalovirus (CMV) infection is common worldwide, but the majority are asymptomatic. However, during initial infection or reactivation, CMV can cause tissue-invasive end-organ damage including in the gastrointestinal tract, especially in immunocompromised individuals. Gastrointestinal CMV disease can present with myriad of symptoms and be highly variable endoscopically. In this article we review the manifestations of CMV infection within the luminal gastrointestinal tract and discuss the options for diagnosis and management.

Cytomegalovirus enterocolitis in apparently immunocompetent hosts: evaluation of the radiologic findings and clinical features

OBJECTIVE

To describe the clinical and radiologic features of cytomegalovirus (CMV) enterocolitis in apparently immunocompetent hosts.

MATERIALS AND METHODS

Our institutional review board approved this retrospective study, and informed consent was waived. Twelve apparently immunocompetent patients (7 women and 5 men; mean age, 58 years) with pathologically proven CMV enterocolitis were included. Computed tomographic (CT) scans were retrospectively reviewed to determine the extent and the location of mural thickening, maximal mural thickness, enhancement pattern, that is, single-halo, double-halo, and homogeneous patterns, and ascites.

RESULTS

Eight patients had comorbidities potentially affecting the host immune status, whereas 4 patients were apparently healthy before presentation. On CT, all patients showed mural thickening (range, 4-11 mm) involving the colon (n = 8), the small bowel (n = 1), or both (n = 3). Segmental involvement was most common (n = 9 for colon and n = 2 for small bowel), whereas focal involvement of the rectum (n = 1) and diffuse involvement of the entire ileum (n = 1) or the entire small bowel and colon (n = 1) were also noted. Colonic lesions showed variable enhancement patterns, including the single-halo (n = 6), homogeneous (n = 3), and double-halo patterns (n = 2), whereas all small-bowel lesions in 4 patients exhibited a single-ring pattern. Ascites was present in 7 patients. Complications requiring surgery occurred in 3 patients and included refractory bleeding (n = 2) and bowel perforation (n = 1).

CONCLUSIONS

Cytomegalovirus enterocolitis in immunocompetent hosts typically develops in elderly subjects with comorbidities, although it may also affect relatively young and healthy subjects. On CT, it is characterized by mild mural thickening of the small bowel and the colon and frequently shows segmental involvement and a single-halo enhancement pattern.

Cytomegalovirus colitis in patients without inflammatory bowel disease: a single center study

OBJECTIVE

Cytomegalovirus (CMV) aggravates preexisting inflammatory bowel disease (IBD), and there are numerous reports of CMV colitis in IBD patients. However, little attention has been paid to CMV colitis in non-IBD patients. The aim was to determine the clinical manifestations, endoscopic appearance, and clinical course of CMV colitis in non-IBD patients.

MATERIAL AND METHODS

We reviewed medical records of patients diagnosed with CMV colitis based on immunohistochemical studies of biopsy specimens or surgical specimens between 1998 and 2009.

RESULTS

The medical records of 43 patients were reviewed. Subjects included individuals with AIDS, and those undergoing chemotherapy, steroid therapy, or transplantation, as well as individuals with other co-morbidities and individuals with no previous illnesses. Frequent symptoms were non-bloody diarrhea, abdominal pain, fever, and hematochezia. Macroscopically normal rectosigmoid mucosa was observed in eight of 21 patients who underwent full-length colonoscopy. Endoscopic findings were varied, and included macroscopically normal (n = 2), colitis alone (n = 12), ulcer alone (n = 5), and ulcer with colitis (n = 22). The ulcer margin was well-circumscribed in 12 of 21 patients. Thirty-six patients were administered antiviral agents and two patients died. All patients who were not treated with an antiviral agent recovered spontaneously while waiting for their biopsy results.

CONCLUSIONS

Colonoscopy is preferred to sigmoidoscopy for diagnosis of CMV colitis. Antiviral therapy should not be mandatory for a subset of patients with CMV colitis.

Rectovaginal fistula

Despite the prevalence and severe implications of rectovaginal fistula, there is no universally accepted evidence-based approach to surgical management. This article offers a disease-based review of traditional management strategies and highlights the variety of technical approaches that are currently effective for the eradication of this socially disabling condition.

Life-threatening rectal bleeding due to cytomegalovirus colitis in a haemodialysis patient

Cytomegalovirus (CMV) disease is a well-recognized complication in immunocompromised patients such as renal transplant recipients, occurring due to reactivation of latent infection or primary infection. It is, however, uncommon in immunocompetent patients. We report a haemodialysis patient who presented with pyrexia and life-threatening rectal bleeding due to CMV colitis, who had none of the classical risk factors for CMV disease, although was at risk. We review the literature surrounding CMV colitis in immunocompetent patients. This case highlights the importance of considering unusual causes for the common presentation of rectal bleeding in vulnerable patient populations.

Cytomegalovirus and inflammatory bowel disease: is there a link?

The objective of this report is to give an overall view of the epidemiological, clinical, diagnostic and therapeutic features of Cytomegalovirus (CMV) infection in inflammatory bowel disease (IBD). A review of published reports on this topic was carried out, with particular attention paid to the selection of patients included in studies and the diagnostic methods employed. CMV is frequently associated with IBD. In some cases, CMV infection is associated with a poor outcome but it is not clear which patients are more likely to be affected and in which stage of the disease. The use of anti-viral therapy in IBD is controversial and an empirical study with controls is needed. The natural history of CMV infection related to the development and treatment of IBD has not been clarified but it is important to take it in consideration because of the possibility of viral persistence in the immunocompromised host and viral interaction with the immune system.

Cytomegalovirus cholangitis and pancreatitis in an immunocompetent patient

Cholangitis and pancreatitis associated with cytomegalovirus (CMV) infection in an immunocompetent patient is reported. Endoscopic retrograde cholangiography performed on a 55-year-old man for evaluation of the cause of jaundice and liver dysfunction revealed a distal focal irregular narrowing of the common bile duct. Microscopic findings of the resected specimen showed chronic cholangitis and CMV pancreatitis. Immunohistochemistry disclosed that epithelial cells in the inflamed bile duct were positive for CMV antigen, which was compatible with CMV cholangitis. Inflammation of the biliary tract or pancreas by CMV has been commonly reported as a complication in immunocompromised patients. Our report appears to be a rare case, but suggests that CMV cholangitis or pancreatitis should be considered in the differential diagnoses of common bile duct stenosis or pancreatitis even in immunocompetent individuals.

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.

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.

Human cytomegalovirus infection of the gastrointestinal tract in apparently immunocompetent patients

Human cytomegalovirus (HCMV) infection is usually reported in immunocompromised patients. This study reports 11 cases of HCMV infection of the gastrointestinal (GI) tract diagnosed in apparently immunocompetent hosts. The median age of the patients studied was 76 years, and the major presenting symptoms were diarrhea, epigastric pain, and abdominal discomfort. The large intestine was involved in 6 cases, the stomach in 4 cases, and the lower esophagus in 1 case. Endoscopy revealed ulcers or hypertrophic folds in the GI tract and single ulcers or erosions in the colon and rectum. Light microscopy showed chronic inflammatory infiltrate in the lamina propria in all cases. The diagnosis of HCMV infection was based on the histological and immunohistochemical identification of HCMV inclusion bodies in different cell types, including epithelial, endothelial, stromal, and smooth muscle cells. Both "classical" inclusions, characterized by an "owl's eye" appearance, and atypical inclusions were found. For all patients, no apparent causes of immunodeficiency were detected at the time of diagnosis of HCMV infection. At follow-up, however, 4 patients were found to harbor a malignant tumor (ie, pancreas, lung, Vater's papilla, and extrahepatic bile duct) at an interval of 2 to 5 months after the diagnosis of HCMV infection. Especially in elderly patients, HCMV infection of the GI tract might be an early clue to the presence of immunologic defects induced by an underlying neoplasia.

[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.

Cytomegalovirus infection in immunocompetent patients

Symptoms associated with cytomegalovirus (CMV) infection in immunocompetent patients are not well documented. From December 1998 through June 2001, serum samples obtained from 7630 patients in Cambridge and Chelmsford, United Kingdom, were tested for CMV immunoglobulin M. CMV immunoglobulin G avidity was used to confirm CMV infection. A total of 124 patients (106 patients treated by general practitioners [GPs] and 18 hospitalized patients) with CMV infection were identified. The most frequent symptoms were malaise (67%), fever (46%), and sweats (46%), and the most frequent finding was abnormal liver function test results (69%). Twelve percent of patients had a relapsing illness, and many had symptoms that lasted for up to 32 weeks (mean duration of symptoms, 7.8 weeks). GPs reported that there was a significant benefit in making the diagnosis of CMV infection; it provided reassurance and avoided the need for further investigations. We have identified symptoms associated with CMV infection in immunocompetent patients who present to GPs or who are admitted to the hospital.

Gastrointestinal Infections Caused by Cytomegalovirus

Cytomegalovirus (CMV) is an important human pathogen, causing a variety of syndromes ranging from asymptomatic infections to life-threatening end-organ disease. Infections of the gastrointestinal tract are an especially common form of disease caused by CMV and are usually manifest as luminal infections, such as esophagitis or colitis. Solid organ disease caused by CMV is also known to occur, with hepatitis being the most common syndrome. The large majority of cases of tissue-invasive disease caused by CMV have been reported to occur in immunocompromised hosts. Patients at highest risk for serious CMV-mediated disease are commonly HIV infected, recipients of transplants, or are receiving potent immunosuppressive medications. Intriguingly, several recent reports have discussed the previously underappreciated role of serious forms of CMV-mediated disease occurring in immunocompetent patients. This paper reviews several recent reports addressing important aspects related to the diagnosis, treatment, and management of CMV infections of the gastrointestinal tract.

Life-threatening cytomegalovirus colitis in the immunocompetent patient: report of a case and review of the literature

Cytomegalovirus colitis in the immunocompetent patient is an unusual clinical entity. We describe a patient with life-threatening cytomegalovirus colitis in the absence of immune deficiency and review the medical literature available on this topic.

Viral causes of diarrhea

Viruses are important causes of diarrhea. In healthy adults, the main clinical manifestation is acute, self-limited gastroenteritis. Advances in molecular diagnostics have shown that epidemics of acute gastroenteritis most frequently are due to caliciviruses spread through contaminated food or through person-to-person contact. Application of similar technology is needed to make a definitive statement about the role of such candidate viruses as rotavirus, astrovirus, and adenovirus as the cause of nonepidemic acute gastroenteritis in adults. Rarely a previously healthy adult gets acute CMV colitis. CMV and EBV mainly cause diarrhea in immunocompromised patients, however. Advances in prophylaxis and treatment have reduced the frequency and severity of these diseases. Acute infantile gastroenteritis is caused by rotavirus, calcivirus, astrovirus, and adenovirus. These viral diseases of the gut are seen by the physician as routine and rare clinical problems.

Toxic megacolon: remember cytomegalovirus

A 63-year-old female retired clerical officer was admitted with a 1-week history of profuse diarrhoea. The patient had been diagnosed with non-Hodgkin's lymphoma 4 years previously, and a human immunodeficiency virus (HIV) test at that time was negative. She had received two regimens of chemotherapy, and had been in remission for 3 months with a normal leukocyte count. The diarrhoea was watery with no blood or mucus, and associated with mild nausea and diffuse left-sided abdominal pain relieved by defaecation. The patient had a mild pyrexia and scanty bowel sounds, but the abdomen was not distended. Full blood count and full biochemistry were normal apart from the white cell count (13.8x109/litre — predominantly neutrophils and monocytes). Initial blood cultures and routine viral serology were negative, but the latter was never repeated. Stool samples were negative for bacteria, parasites and toxins.

Clinical evaluation and management of acute severe colitis

This review concentrates on the clinical evaluation, imaging, therapy, and prognostic factors in acute severe colitis of idiopathic as well as infectious origin. Older concepts as well as more recent are critically scrutinized.