Cytomegalovirus ileo-pancolitis presenting as toxic megacolon in an immunocompetent patient: A case report

Abstract

Background: Cytomegalovirus (CMV) enterocolitis presenting in the form of pancolitis or involving the small and large intestines in an immunocompetent patient is rarely encountered, and CMV enterocolitis presenting with a serious complication, such as toxic megacolon, in an immunocompetent adult has only been reported on a few occasions.

Case summary: We describe the case of a 70-year-old male with no history of inflammatory bowel disease or immunodeficiency who presented with toxic megacolon and subsequently developed massive hemorrhage as a complication of CMV ileo-pancolitis. The patient was referred to our institute for abdominal pain and distension. Abdominal X-ray showed marked dilatation of ileum and whole colon without air-fluid level, and sigmoidoscopy with biopsy failed to reveal any specific finding. After 7 d of conservative treatment, massive hematochezia developed, and he was diagnosed to have CMV enterocolitis by colonoscopy with biopsy. Although the diagnosis of CMV enterocolitis was delayed, the patient was treated successfully by repeat colonoscopic decompression and antiviral therapy with intravenous ganciclovir.

Conclusion: This report cautions that CMV-induced colitis should be considered as a possible differential diagnosis in a patient with intractable symptoms of enterocolitis or megacolon of unknown cause, even when the patient is non-immunocompromised.

Keywords: Case report; Cytomegalovirus; Enterocolitis; Immunocompetent; Toxic megacolon.

Figure 1

An X-ray image of the abdomen. Abdominal film showing marked distensions of loops of the large and small intestines.

Figure 2

Colonoscopy images. A-C: Colonoscopy images obtained on hospital day 8 (the next day of the first episode of massive hematochezia), showing huge, variably-sized, multiple, diffuse, deep ulcers at cecum (A) and sigmoid colon (B), and multiple healing stages ulcers at distal ileum (C); D, E: Follow-up colonoscopy images obtained on hospital day 10 showing oozing blood and multiple ulcers at ascending colon (D) and diffuse, huge ulcers at rectum (E); F-H: Follow-up colonoscopy images obtained on hospital day 14 (7 d after the first hematochezia event) showing huge and variably-sized, multiple, diffuse, healing stage ulcers with pinkish granulation tissue bases on cecum (F) and sigmoid colon (G), and multiple healing stage ulcers in distal ileum (H); I, J: Last follow-up colonoscopy image obtained after 2 mo of discharge showing several ulcer scars in cecum (I) and rectum (J) but no specific lesion.

Figure 3

Pathology findings of hematoxylin-eosin and immunohistochemical stained biopsy sections. A: The black arrow shows cytomegalovirus inclusion bodies (HE staining, × 400); B: Orange arrows show cytomegalovirus-positive cells (immunohistochemical staining, × 400).