A Rare Case of Herpes Simplex Virus and Cytomegalovirus Dual Infection Inducing Unremitting Ulcerative Colitis

Abstract

Ulcerative colitis (UC) is a subtype of inflammatory bowel disease that results in inflammation and ulceration in the lining of the large intestine. Patients with UC are frequently prescribed immunosuppressive medications to treat their symptoms, resulting in an increased risk of reactivation of many latent viruses, including herpes simplex virus (HSV) and cytomegalovirus (CMV). However, it is rare for a patient to present with simultaneous reactivation of both viruses. Here, we document the presentation, hospital course, and clinical findings of a UC patient with HSV and CMV dual infection. We also describe treatment strategies and prophylactic measures for managing a dual infection. This is seen through initiating valganciclovir in the outpatient setting following the diagnosis.

Keywords: cytomegalovirus; herpes simplex virus; immunosuppression complications; inflammatory bowel disease; ulcerative colitis.

Figure 1. Colonoscopy findings

Mild (Mayo Score 1) ulcerative colitis in the cecum. Moderately active (Mayo Score 2) ulcerative colitis from the rectum to the ascending colon with scattered pseudopolyps and segmental narrowing in the sigmoid, descending, and transverse colon.

Figure 2. Biopsy images

A: A rare epithelial cell is shown by H&E at 40X magnification with an enlarged nucleoli-like structure (center cell), which is suggestive of a CMV nuclear inclusion. B: A CMV immunohistochemical stain shows some nuclear staining in some cells. C: An epithelial cell is shown by H&E at 40X magnification with a “ground glass” nuclear appearance and an adjacent multinucleated cell on the right, which are cytologic features seen with Herpes-infected epithelial cells. D: An immunohistochemical stain for HSV 1/2 is performed, which shows occasional cytoplasmic-positive cells.