Coexisting cytomegalovirus infection in immunocompetent patients with Clostridium difficile colitis

Abstract

Cytomegalovirus (CMV) colitis usually occurs in immunocompromised patients with human immunodeficiency virus infection, organ transplantation, and malignancy receiving chemotherapy or ulcerative colitis receiving immunosuppressive agents. However, CMV colitis is increasingly recognized in immunocompetent hosts. Notably, CMV colitis coexisting with Clostridium difficile infection (CDI) in apparently healthy individuals has been published in recent years, which could result in high morbidity and mortality. CMV colitis is a rare but possible differential diagnosis in immunocompetent patients with abdominal pain, watery, or especially bloody diarrhea, which could be refractory to standard treatment for CDI. As a characteristic of CDI, however, pseudomembranous colitis may be only caused by CMV infection. Real-time CMV-polymerase chain reaction (PCR) for blood and stool samples may be a useful and noninvasive diagnostic strategy to identify CMV infection when treatment of CDI eventually fails to show significant benefits. Quantitative CMV-PCR in mucosal biopsies may increase the diagnostic yield of traditional histopathology. CMV colitis is potentially life-threatening if severe complications occur, such as sepsis secondary to colitis, massive colorectal bleeding, toxic megacolon, and colonic perforation, so that may necessitate pre-emptive antiviral treatment for those who are positive for CMV-PCR in blood and/or stool samples while pending histological diagnosis.

Case–Control Study of Inflammatory Bowel Disease Patients with and without Clostridium difficile Infection and Poor Outcomes in Patients Coinfected with C. difficile and Cytomegalovirus

“…Conversely, our study revealed a higher rate of CMV coinfection in IBD patients with CDI and the association with poorer outcomes. A review article reported clinical scenario of coexisting cytomegalovirus infection in immunocompetent patients with CDI [ 28 ]. In cases of coexisting CMV and C. difficile colitis, ganciclovir therapy for CMV colitis in time may circumvent the unnecessary second-line therapeutic method for CDI, supposing that persistent diarrhea was not due to treatment failure for C. difficile [ 28 ].…”

“…A review article reported clinical scenario of coexisting cytomegalovirus infection in immunocompetent patients with CDI [ 28 ]. In cases of coexisting CMV and C. difficile colitis, ganciclovir therapy for CMV colitis in time may circumvent the unnecessary second-line therapeutic method for CDI, supposing that persistent diarrhea was not due to treatment failure for C. difficile [ 28 ]. In our clinical practice, coinfection is mostly seen in severe patients or those who received consequent or joined immunosuppressive medications.…”

Failure to Recognize the Diagnosis of Cytomegalovirus Colitis in an Immunocompetent Male: Need for Heightened Index of Suspicion

“…Clostridium difficileassociated colitis has become a problem in the United States and was suspected despite several negative assays [23]. Negative assays do not exclude C. difficile infection, however, one should always consider other enteric infections even if pseudomembranous colitis is observed on colonoscopy [24]. Cytomegalovirus has the potential to mimic CDAC; also co-infection with multiple pathogens both in immunosuppressed and immunocompetent patients has been observed [3,25].…”

Mouse Gamma Herpesvirus MHV-68 Induces Severe Gastrointestinal (GI) Dilatation in Interferon Gamma Receptor-Deficient Mice (IFNγR−/−) That Is Blocked by Interleukin-10

“…EBV and KSHV are associated with a range of diseases from infectious mononucleosis and lymphoma to nasopharyngeal carcinoma and Kaposi’s sarcoma. Herpesviruses such as EBV and the beta herpesvirus, cytomegalovirus (CMV), are also implicated in inflammatory bowel disease (IBD) [ 4 , 5 , 6 , 7 , 8 , 9 ]. MHV-68 infection causes a lethal sepsis in interferon gamma receptor-deficient (IFNγR −/− ) mice with large vessel vasculitis, pulmonary hemorrhage, and consolidation, while in wildtype (WT) mice MHV-68 produces a benign infection that can become latent [ 1 , 2 , 3 , 10 , 11 , 12 , 13 , 14 ].…”

“…Gastrointestinal (GI) dilatation, also referred to as GI distension, is a clinically significant condition with diverse etiologies including IBD, Clostridium difficile colitis after antibiotic treatment, irritable bowel syndrome, diabetes, functional dyspepsia, transient constipation, parasitic infection such as giardia or nematodes, bacterial food poisoning, celiac disease, severe peptic ulcer disease, bowel obstruction, immunosuppression and, in some cases, as a complication following abdominal surgery [ 4 , 5 , 6 , 7 , 8 , 9 , 18 , 19 , 20 , 21 ]. Patients with GI dilatation experience nausea, abdominal pressure, pain, or cramping.…”