CMV Colitis Mimicking Recurrent Inflammatory Bowel Disease: Report of Three Cases

Abstract

The association between cytomegalovirus infection and inflammatory bowel disease challenges both the clinician and the pathologist to establish the correct diagnosis and to prescribe the most appropriate form of therapy. To understand this association the authors report three patients who presented with signs and symptoms mimicking reactivated inflammatory bowel disease who responded poorly to aggressive treatment of inflammatory bowel disease. Microscopic examination, in all three cases revealed numerous nuclear and cytoplasmic viral inclusions, as demonstrated by cytomegalovirus immunohistochemistry, as well as histologic findings consistent with inflammatory bowel disease (ulcerative colitis and/or Crohn's disease). Because the clinical pathologic features of cytomegalovirus colitis and inflammatory bowel disease often overlap, and because of the possible coexistence of cytomegalovirus colitis with idiopathic colitis, the possibility of cytomegalovirus infection should be always considered, so that the most appropriate therapy can be instituted for these patients.

The clinical spectrum of cytomegalovirus colitis in adults

“…These scattered anecdotal reports were collected in a recently published meta‐analysis 16 . A few more isolated case reports have been published lately 17–23 . Recently, we observed similar individuals, who without any obvious immunosuppressive state or previous IBD, developed colonic inflammation stemming from CMV infection.…”

“…In this retrospective observational study, we revealed that CMV colitis is a rare occurrence but not as rare as is described in the medical literature. During a time period of 12 years we were able to collect 19 patients from our medical centre, by combining molecular virological and pathological findings, while others were able to report fewer than 50 similar patients from multiple medical facilities throughout the world in a period of 26 years (1980–2006) 16–23 …”

Cytomegalovirus disease in immunocompetent adults

“…Although uncommon, severe CMV infection in immunocompetent adults often poses a significant diagnostic challenge, and a number of case reports have documented considerable delay to diagnosis 14 . ‐ 16 Some patients with CMV colitis, in particular, have had protracted hospitalisations and have undergone surgery to investigate persistent and undiagnosed disease.…”

“…Third, certain presentations of CMV disease strongly mimic other diseases, potentially causing diagnostic confusion and delay in diagnosis. Indeed, case studies have documented initial misdiagnoses of colon carcinoma, 14 ischaemic colitis, 15 inflammatory bowel disease, 16 dengue fever 17 and lung cancer, 18 among others.…”

Cytomegalovirus Colitis: An Uncommon Mimicker of Common Colitides

“…17 Cobblestone-like confluent ulcers may also be seen on a pale, flattened mucosa, which can range in size from 0.7 to 2.8 cm, closely mimicking Crohn disease. 10,18 Occasionally pseudomembranes and pseudopolyps may be detected, findings that can be pitfalls in the misdiagnosis of CMV colitis as pseudomembranous colitis. 9 One study found that 11 of 44 patients with CMV colitis (25%) had normal colonic mucosa on endoscopy but histologic evidence of CMV on biopsy.…”