1571 A Case of CMV Colitis Seen in DRESS

Abstract

INTRODUCTION: Cytomegalovirus (CMV) is a member of the family of herpes virus, which persists for life after a primary infection. It is known to cause colitis in both immunocompromised and immunocompetent hosts. This virus is prevalent in about 50%-80% of the general adult population. CMV enters a latency phase after initial infection. Reactivation can occur anywhere along the gastrointestinal tract. The colonic mucosa is the most common site of reactivation. Clinical, endoscopic, and histological appearance of CMV colitis can mimic inflammatory bowel disease. Given this circumstance is it important to avoid misdiagnosis and mismanagement of CMV colitis given high morbidity associated with it. CASE DESCRIPTION/METHODS: A 59-year-old female with rheumatoid arthritis on chronic steroids and recently prescribed leflunomide presented with a diffuse rash, stomatitis, eosinophilic dominant leukocytosis, and severe diarrhea. A skin biopsy confirmed the diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS). The patient's diarrhea worsened despite negative comprehensive stool panel, clostridium difficile toxin and stool ova/parasites. A CT abdomen revealed diffuse colitis, and as a result the patient underwent flexible sigmoidoscopy showing circumferential colitis with ulcerations (Figure 1). Biopsies taken from the distal colon confirmed Cytomegalovirus (CMV) by viral inclusion bodies seen on hematoxylin-eosin staining (Figure 2). The patient was initiated on IV ganciclovir, however expired after developing septic shock. DISCUSSION: Gastrointestinal (GI) disease caused by CMV is diagnosed on the presence of clinical symptoms, viral inclusion bodies on biopsy, and endoscopically visualized ulcers. The most common sites of CMV related GI involvement is the esophagus and colon. Biopsy with immunohistochemical testing using monoclonal antibodies against CMV is considered the gold standard (Figure 3). Owl's eye inclusion bodies on staining are highly specific for infection with CMV. The gastrointestinal tract is thought to contain latent CMV after a primary infection This case highlights the importance of recognizing the risks of long term medical treatment with immunomodulatory drugs such as leflunomide or corticosteroids, including local reactivation of a latent virus as in our patient.

Tocilizumab-induced Cytomegalovirus Colitis in a Patient with COVID-19

“…12 The characteristic Owl's eye inclusion bodies are highly specific for CMV. 13 CMV colitis and IBD closely mimics each other in their clinical, endoscopic and histological appearance. Therefore, it is crucial to avoid misdiagnosis and mismanagement, keeping in mind the high morbidity associated with it.…”

Tocilizumab‐induced cytomegalovirus colitis in a patient with COVID‐19

“…Biopsy with immunohistochemistry using monoclonal antibodies against CMV antigens is now considered the gold standard 14 . The characteristic Owl's eye inclusion bodies are highly specific for CMV 15 . The human blood‐derived products (convalescent plasma, immunoglobulin) and immune‐modulatory therapies, like tocilizumab and corticosteroids, studied extensively for the treatment of severe SARS‐CoV‐2 infection.…”

“…14 The characteristic Owl's eye inclusion bodies are highly specific for CMV. 15 The human blood-derived products (convalescent plasma, immunoglobulin) and immune-modulatory therapies, like tocilizumab and corticosteroids, studied extensively for the treatment of severe SARS-CoV-2 infection. In the RECOVERY trial, 16 dexamethasone therapy has shown a mortality benefit among COVID 19 patients who were requiring supplemental oxygen.…”