2056 CMV Colitis Superimposed on Ischemic Colitis in an Immunocompetent Individual

Abstract

INTRODUCTION: Cytomegalovirus (CMV) infections are more commonly seen in individuals with immunosuppressive diseases. We present a unique case of CMV colitis superimposed as ischemic colitis in an immunocompetent individual. CASE DESCRIPTION/METHODS: A 68-year-old man with history of PE (on Xarelto), pneumothorax & COPD presented with 10 weeks of diarrhea, associated with chills, lower abdominal discomfort, poor appetite, and weight loss of 15 pounds. Rectal exam showed dark stool and FOBT was positive Lab data showed elevated ESR and CRP. All stool studies were negative. CT Abdomen reported colonic findings suggestive of colitis with areas of active inflammation. Colonoscopy showed inflammation characterized by congestion (edema), erosions, granularity & ulcerations in a continuous and circumferential pattern from the sigmoid colon to the terminal ileum with sparing of mid & distal sigmoid colon and the rectum (Figures 1 and 2). Preliminary biopsies were suspicious for Crohns Disease. Patient was started on PO Prednisone 60 mgs daily & Pentasa TID and discharged for close follow up with GI. He kept on failing outpatient treatment, and was re-admitted twice with worsening of symptoms. Repeat CT scans showed worsening diffuse colitis. C Diff was checked, which was –ve. He was re-started on IV Abx, IV Steroids and supportive care. His symptoms continued to worsen, so Colorectal Surgery was consulted and, he underwent open subtotal colectomy. Pathology Slides from the Surgical Specimen were diagnostic for Ischemic looking bowel, and showed no features of IBD. So, decision was made to send the slides for second opinion. Meanwhile, he continued to deteriorate, so he was taken for emergent exploratory laparotomy and was found to have diffusely ischemic and distended bowel. Confirmation of pathology was not consistent with IBD. It showed Ischemic ileocolitis with possible superimposed CMV colitis with CMV inclusion bodies (Figure 3). IV Ganciclovir was initiated, steroids were discontinued. He began to improve, diet was advanced and was discharged with GI follow up. DISCUSSION: Suspicion of CMV colitis should be investigated by endoscopic evidence. The typical findings such as owl’s eye inclusion bodies on histology is specific for CMV. This is an unusual case of CMV associated ischemic colitis in an immunocompetent individual. This case report also should sound an alarm to GI physicians on thinking about CMV colitis infections even in immunocompetent individuals.