Cytomegalovirus enterocolitis with subsequent diagnosis of coexisting new-onset inflammatory bowel disease

Abstract

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.

Protective role of flavonoids quercetin and silymarin in the viral-associated inflammatory bowel disease: an updated review

“…Conversely, CD4 + T cells produce interferon alpha (IFN-α) in the CD which precludes the CMV reactivation resulting in lower rate of infection and consequent inflammation (Nakase et al 2010 ; McCurdy et al 2015 ). The CMV and IBD association which can exacerbate the IBD conditions has been described for long years, though debates remains open on the development of severe disease (Powell et al 1961 ; Luangsirithanya et al 2021 ; O’Connor 2021 ). The CMV rate of infection in China has been higher in the UC than CD (Yang and Qian 2022 ).…”

“…The inflammation of the epithelium is consequent to the stimulation of immune responses by the CMV proteins (Lv et al 2017 ). In IBD patients, the proinflammatory cytokines such as TNF-α, interferon-γ and interleukin-2 (IL-2) released by inflammatory or epithelial cells result in the enhancement of chemokines and transcription molecules and subsequent CMV reactivation (Luangsirithanya et al 2021 ). The CMV existence in colonic biopsies and its clinical relevance is controversial in spite of observations of refractory illness in pediatric patients (Hommes et al 2004 ).…”

Cytomegalovirus Diseases of the Gastrointestinal Tract in Immunocompetent Patients: A Narrative Review

“…Thus, screening for CMV in patients with IBD experiencing acute flares or refractory treatments is essential. Intriguingly, a literature review by Luangsirithanya et al described 13 cases of new-onset IBD with coexisting CMV colitis, revealing that IBD should be suspected in immunocompetent patients with CMV GI disease, especially if they have a partial response to AVT [ 115 ]. With respect to malignancy, Costa et al reported a case of an atypical bronchopulmonary carcinoid tumor, revealed by a positron emission tomography scan arranged as a survey for possible immunodeficiency after the diagnosis of CMV duodenitis [ 116 ].…”