Cytomegalovirus Colitis and Subsequent New Diagnosis of Inflammatory Bowel Disease in an Immunocompetent Host: A Case Study and Literature Review

Integrating transcriptomics and proteomics to analyze the immune microenvironment of cytomegalovirus associated ulcerative colitis and identify relevant biomarkers

BACKGROUND

In recent years, significant morbidity and mortality in patients with severe inflammatory bowel disease (IBD) and cytomegalovirus (CMV) have drawn considerable attention to the status of CMV infection in the intestinal mucosa of IBD patients and its role in disease progression. However, there is currently no high-throughput sequencing data for ulcerative colitis patients with CMV infection (CMV + UC), and the immune microenvironment in CMV + UC patients have yet to be explored.

METHOD

The xCell algorithm was used for evaluate the immune microenvironment of CMV + UC patients. Then, WGCNA analysis was explored to obtain the co-expression modules between abnormal immune cells and gene level or protein level. Next, three machine learning approach include Random Forest, SVM-rfe, and Lasso were used to filter candidate biomarkers. Finally, Best Subset Selection algorithms was performed to construct the diagnostic model.

RESULTS

In this study, we performed transcriptomic and proteomic sequencing on CMV + UC patients to establish a comprehensive immune microenvironment profile and found 11 specific abnormal immune cells in CMV + UC group. After using multi-omics integration algorithms, we identified seven co-expression gene modules and five co-expression protein modules. Subsequently, we utilized various machine learning algorithms to identify key biomarkers with diagnostic efficacy and constructed an early diagnostic model. We identified a total of eight biomarkers (PPP1R12B, CIRBP, CSNK2A2, DNAJB11, PIK3R4, RRBP1, STX5, TMEM214) that play crucial roles in the immune microenvironment of CMV + UC and exhibit superior diagnostic performance for CMV + UC.

CONCLUSION

This 8 biomarkers model offers a new paradigm for the diagnosis and treatment of IBD patients post-CMV infection. Further research into this model will be significant for understanding the changes in the host immune microenvironment following CMV infection.

Respiratory failure in a tofacitinib treated patient with ulcerative colitis

Tofacitinib is an oral Janus Kinase (JAK) inhibitor recently approved for the management of moderate to severe ulcerative colitis (UC). Safety data on tofacitinib has suggested a moderately increased risk for venous thromboembolism (VTE) as well as non-opportunistic infections and non-infectious drug-related lung disease. We faced a diagnostic dilemma between an infectious and non-infectious cause of acute respiratory insufficiency in a patient on recent tofacitinib therapy. A lung CT scan showed bilateral interstitial pneumonic infiltrates and a PCR on bronchoalveolar lavage fluid was positive for cytomegalovirus (CMV). The patient’s condition improved after discontinuation of tofacitinib and treatment with anti-viral drugs and high dose corticosteroids. A CMV primary infection was suspected, however a drug-induced interstitial lung disease cannot be excluded in the differential diagnosis of patients with autoimmune disorders under tofacitinib therapy who present with fever, hypoxia and pulmonary infiltrates.

Cytomegalovirus hemorrhagic colitis in an immunocompetent patient with COVID-19 infection: A case report

In coronavirus disease-19, we should suspect the opportunistic coinfections even in immunocompetent individuals. In the presence of recurrent gastrointestinal problems, colonoscopy should be done with biopsy and histopathology to diagnose the opportunistic infection, such as cytomegalovirus colitis, in patient with coronavirus disease-19. Here, we report a case of immunocompetent male with coronavirus disease-19 presenting with per rectal bleeding diagnosed as cytomegalovirus colitis.

The Overlooked Agent: Cytomegalovirus Colitis in an Immunocompetent Patient

Cytomegalovirus (CMV) colitis is usually associated with immunosuppressed patients, which by the classic definition are individuals who have immunosuppressed associated conditions (human immunodeficiency virus [HIV], oncology diseases, inflammatory bowel disease, transplant patients) or who are submitted to immunosuppressing therapies (for instance, corticosteroids, chemotherapeutic agents or immunomodulation therapies). In immunocompetent patients, this diagnosis tends to be often missed, leading to a delay in initiating proper management. We present a case of a 91-year-old woman that was diagnosed with CMV colitis without any identified formal immunocompromising factors. We intend to highlight the need to review the definition of an immunosuppressed individual and emphasize that CMV colitis should be considered in the differential diagnosis, especially in elderly patients and those with underlying conditions that can possibly affect their immune status, since prompt diagnosis and treatment are essential and influence the prognosis.

Cytomegaloviral colitis in primary CMV viraemia in a young immunocompetent adult

A man in his 20s presented with a 2-week history of fever, fatigue and diarrhoea. On arrival to the emergency department, he had clinical findings of sepsis. The care team initially suspected sepsis secondary to bacterial colitis and administered antibiotics. Further workup including a stool PCR assay for gastrointestinal pathogens failed to establish a diagnosis, and he had no evidence of immune compromise. Colonoscopy revealed mucosal ulceration presumed to be ulcerative colitis. Histopathology obtained after discharge revealed severe colitis with cytomegalovirus (CMV) inclusions. Serological studies indicated a primary CMV infection. To our knowledge, this is the first report of a primary CMV infection presenting as severe colitis and systemic disease in a young immunocompetent patient without underlying disease.

Routine Histology-Based Diagnosis of CMV Colitis Was Rare in Pediatric Patients

Cytomegalovirus (CMV) induced or complicated colitis is important to identify, yet its incidence is unknown among pediatric patients. We aimed to establish the incidence of routine histology-confirmed CMV colitis among pediatric patients with colitis. Pathology reports at Texas Children's Hospital (TCH) between January 1, 2011 and November 6, 2019 were reviewed. Of 1801 cases of histologic colitis, 11 patients had CMV found by histology (mean age 15.4, 72.7% female), with an incidence of 0.6%. Nine out of these 11 (81.8%) patients were immunocompromised and 4 (36.4%) had inflammatory bowel disease (IBD) as an underlying diagnosis of whom 2 had new-onset ulcerative colitis. At an average follow-up of 3.7 years, none of the CMV colitis cases experienced recurrence or severe complications (such as colectomy). An independent analysis of 54 consecutive IBD-associated colectomy cases at TCH showed no histologic evidence of CMV. We conclude that routine histology proven CMV-associated colitis in pediatric patients and IBD-colon explants was rare.Key Words: cytomegalovirus; colitis; children; histopathology; ulcerative colitis.

Cytomegalovirus colitis with a new diagnosis of ulcerative colitis in an elderly woman

Objectives: Cytomegalovirus (CMV) colitis is generally diagnosed in immunocompromised patients. It is rare for patients who are not immunocompromised to develop CMV colitis. Cases of CMV colitis in patients with inflammatory bowel disease have also been reported. We encountered a case of CMV colitis with a new diagnosis of severe ulcerative colitis and demonstrated the importance of suspecting ulcerative colitis in immunocompetent patients with CMV colitis.

Patient: A 78-year-old woman was hospitalized with fever and diarrhea that had lasted for a month. Colonoscopy revealed continuous diffuse edema, mucosal redness, and multiple punched-out ulcers with bleeding, suggesting cytomegalovirus (CMV) colitis, although she was not immunocompromised. Immunohistochemical staining revealed CMV-positive cells, and CMV colitis was diagnosed. One month later, a colonoscopy was conducted owing to persistent symptoms despite initiating the prescribed antiviral drug. A complete loss of vascular pattern, easy bleeding of the crude mucosa, and exacerbation of multiple punched-out ulcers were observed. She was diagnosed with severe ulcerative colitis. The symptoms of ulcerative colitis disappeared with prednisolone and 5-amino salicylic acid treatment.

Conclusion: Ulcerative colitis should be suspected in immunocompetent patients with CMV colitis.

Cytomegalovirus in pediatric inflammatory bowel disease patients with acute severe colitis

BACKGROUND

The prevalence and significance of cytomegalovirus (CMV) colitis in pediatric acute severe colitis is unknown. The aim of this study was to determine the prevalence of CMV in colonic mucosa of children with acute severe refractory colitis and compare the clinical characteristics and outcomes of CMV positive and negative patients.

METHODS

In a case-control study, colonic biopsy specimens from children with severe refractory colitis were tested for CMV, and matched with non-refractory IBD controls. We characterized CMV positive patients by assessing laboratory values, concurrent medications, and need for surgery as compared with CMV negative refractory colitis patients.

RESULTS

Colonic biopsies from 96 patients were evaluated for CMV; 48 with severe refractory colitis, and 48 non-refractory controls. There was an increased prevalence of CMV in severe refractory colitis [7/48 (14.6%), P < 0.0001]; all were previously CMV negative. Viral DNA burden on immunohistochemistry was not predictive of response to antiviral therapy or need for surgery at 12 months. Lymphopenia was seen in all CMV positive patients, but this did not demonstrate statistical significance (P = 0.09). We did not see an association between azathioprine or infliximab use and the need for surgery at 12 months.

CONCLUSIONS

There is an increased prevalence of CMV in colonic biopsies of pediatric patients with severe refractory colitis. Viral burden does not predict clinical outcomes or subsequent need for colectomy.

Cytomegalovirus gastritis: Clinicopathological profile

BACKGROUND

Cytomegalovirus (CMV) gastritis is occasionally reported in case reports and limited case series. Up to now, it is the largest and most comprehensive retrospective study of CMV gastritis.

METHODS

All patients who were histologically diagnosed with CMV gastritis at Linkou Chang Gung Memorial Hospital between January 2000 and April 2020 were included. Patients were divided into two groups according to immunity. Between-group differences in characteristics, manifestations, endoscopic features, prognostic factors, and outcomes were analyzed. The main endpoint was 3-month mortality.

RESULTS

A total of 54 patients (34 immunocompromised, 20 immunocompetent) were enrolled. Common presentations included gastrointestinal bleeding (35.2%), abdominal pain (33.3%) and fever (31.5%). The endoscopic features included ulcer (88.9%) and inflammation (11.1%). The 3-month mortality rate was 20.4% and overall mortality rate was 40.7%. Acute kidney injury was the only independent risk factor for 3-month mortality (OR 53.89, 95%CI 1.56-1861.73, p = 0.027). Anti-viral therapy and host immune status did not affect 3-month mortality.

CONCLUSION

Both immunocompromised and immunocompetent patients with CMV gastritis have high mortality rates, without significant between-group differences. Acute kidney injury is the only independent predictive factor for 3-month mortality. Prevention of acute kidney injury may possibly improve the 3-month mortality rate.

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.

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.

Acute cytomegalovirus infection in an immunocompetent patient with ulcerative colitis: A case report

Cytomegalovirus (CMV) is a ubiquitous member of the Herpesviridae family that can present with a variety of clinical manifestations, including encephalitis, retinitis, interstitial pneumonia and colitis. These serious symptoms are generally observed as opportunistic infections in immunocompromised hosts, including patients with acquired immunodeficiency syndrome and those receiving steroids and/or immunosuppressants. Symptomatic CMV infections in patients with ulcerative colitis are found in patients treated with steroids and/or immunosuppressants but rarely affect those who are not taking these agents. The present study reported the case of a young patient without concurrent use of immunosuppressive agents for the treatment of ulcerative colitis. The patient presented with acute mononucleosis and colitis caused by primary CMV infection. This was characterized by the presence of atypical lymphocytes and hepatosplenomegaly, elevation of transaminase levels, serology-positive anti-CMV IgM, and CMV antigenemia. Additionally, CMV-positive cells were histologically detected in colonic biopsy specimens. The patient's symptoms and clinical parameters improved following initiation of intravenous ganciclovir. It was concluded that even if patients with ulcerative colitis are not treated with steroids and/or immunosuppressants, significant attention should be paid to acute CMV infections in the context of severe or persistent colonic inflammation.

Clinical characteristics of cytomegalovirus colitis: a 15-year experience from a tertiary reference center

Background

Cytomegalovirus (CMV) colitis is considered rare in immunocompetent patients.

Objective

The predictors of mortality and the differences between immunocompetent and immunocompromised patients with this disease remain unknown. Thus, the aim of this retrospective cohort study was to clarify these issues.

Patients and methods

We enrolled all patients who were histologically diagnosed with CMV colitis between April 2002 and December 2016 in the Linkou Chang Gung Memorial Hospital. Patients were divided into two groups: immunocompetent and immunocompromised, and the differences between them were analyzed to develop in-hospital mortality predictors.

Results

A total of 69 patients (42, immunocompetent; 27, immunocompromised) were enrolled. The most common symptoms were melena in the immunocompetent group and diarrhea in the immunocompromised group. The in-hospital mortality rate showed no statistically significant difference between the two groups (26.2% vs 25.9%, P=0.981). Early diagnosis was the only significant independent predictor of in-hospital mortality (odds ratio [OR] 1.075, 95% CI 1.005-1.149, P=0.035). The cutoff of diagnostic timing was 9 days from admission, derived from the receiver operating characteristic curve using the Youden index.

Conclusion

CMV colitis in immunocompetent patients is markedly more common and fatal than has generally been acknowledged. Being alert to different ways in which this disease can present itself will enable early diagnosis and significantly reduce mortality.