Synchronous cytomegalovirus infection in a newly diagnosed ulcerative colitis patient

A 61-year-old Punjabi female patient presented with six months history of mild abdominal discomfort with bloody diarrhea. She did not have underlying chronic medical illness; she neither took steroid nor immunosuppressant. She was found anemic, thrombocytosis, and elevated C-reactive protein. Colonoscopy showed moderate left sided colitis, with histopathology evidence of ulcerative colitis (UC) with cytomegalovirus (CMV) infection. Her serum anti-CMV IgM antibody was detected. She was treated with intravenous ganciclovir, together with 5-ASA and tapering dose of steroid. Anemia was corrected. Subsequent clinic reviews and follow up endoscopies showed dramatically improvement. CMV colitis should be considered for the patients presenting with moderate to severe UC. Early prescription of antiviral would be beneficial in the treatment of flare of UC.


Introduction
Cytomegalovirus is a member of the Herpesviridae family and is a common infection in humans with a prevalence of over 70%. 1 Disease acquisition is usually asymptomatic in healthy people, but it leads to lifelong latent infection.Blood serology tests show that 60 to 90% of adults have had a CMV infection at some time.
Gastrointestinal infections with CMV, especially colitis, are usually found in immunocompromised patients and rarely affect immunocompetent subjects.The association between inflammatory bowel disease especially UC and CMV has been recognized for over half a decade.There are few reports of CMV colitis in immunocompetent hosts, 2,3 with Blair reported the first case in 1992. 4st of the cases reported as flare of UC with CMV infection.Here, we report a case of synchronous CMV infection in a patient with newly diagnosed UC.Our purpose is therefore to familiarize clinicians involved with the diagnosis and management of gastroenterological diseases with this entity.

Case Report
A 61 year old Punjabi female patient presented with six months history of mild abdominal discomfort with bloody diarrhea.She denied of fever, nor weight loss.She did not have underlying chronic medical illness; she neither took steroid nor immunosuppressant.Further questioning, she denied of family history of inflammatory bowel disease or colorectal cancer.
She was pale, with otherwise normal abdominal examination.
Biochemistry showed normochromic normocytic anemia with hemoglobin level 8.8 g/dL, reactive thrombocytosis; and elevated C-reactive protein.Her stool oval and cyst, and culture both showed negative.Tumor marker CEA was within normal range.Her serum anti-CMV IgM antibody was detected.Colonoscopy showed moderate left sided colitis, with hemorrhagic mucosal erosions at recto-sigmoid region and descending colon (Figure 1), otherwise healthy mucosa of the other parts of the colon till terminal ileum.Few target biopsies taken and the histopathology examination reported as ulcerative colitis (presence of crypt abscesses, cryptitis, crypt distortion, lymphoplasmacytosis, and neutrophil infiltration) (Figure 2) with CMV infection (classical inclusion bodies with nuclear positivities of CMV immunestaining) (Figure 3).Otherwise, no granuloma, dysplasia, or malignancy noted.Tuberculosis had been ruled out as well, proven by the normal skin mantoux test, and clear chest X-ray.
She was warded and blood transfused to keep the haemoglobin level above 10 g/dL.She was treated with two weeks of intraveous ganciclovir (10 mg/kg/day), together with both oral and suppository 5-ASA with intravenous hydrocortisone 100 mg tds initially followed by tapering dose of oral prednisolone over three months.She improved dramatically and discharged well.
Subsequent colonoscopy reviewed mucosal healing (Figure 4).And she is on maintenance dose of oral 5-ASA now.

Discussion
The association between CMV and IBD has remained a topic of ongoing controversy since long ago.In 1961, Powell et al. had described a patient with UC and cytomegalic inclusion disease. 5verall prevalence of CMV is unknown in IBD patients.Most of studies have been carried out using a selected patient group and using different diagnostic methods, so that the available data include a wide range of prevalences of 4.5-70%, which could be biased.Domènech et al. has reported a high prevalence of CMV infection (70%) in UC patients in Spain, 6 which has a similar percentage to that of the general population.Patients with inactive or mild-moderate UC did not show an increased risk of CMV colitis.However, literatures review that the prevalence of CMV infection could be higher in severe or steroid-refractory colitis, with risk factors of female gender, older age, pancolitis and azathioprine treatment. 7,8It is not known whether the virus exacerbates the disease or simply appears as a bystander. 9ypical endoscopic findings of CMV colitis alone are microerosions, deep ulcers and pseudotumoral lesions. 10Most studies in patients with IBD, specifically in active UC, have not found specific endoscopic features. 7,11,12Suzuki et al. found that punched-out ulceration and longitudinal ulceration exhibited relatively high sensitivity and specificity for CMV colitis in inflammatory bowel disease. 13istological diagnosis is considered the gold standard for diagnosing CMV disease in the gastrointestinal tract, 14,15  Most authors recommend the use of antivirals (a full 14 day course of intravenous gancyclovir) in steroid-refractory UC flare-up and CMV positive patients. 6,16,17Antiviral treatment can significantly decrease the mortality rate and need for surgery.

Conclusions
Our report is unique that CMV infection was found in a newly diagnosed ulcerative colitis patient, which is considered as a synchronous finding.CMV colitis should be considered for all patients presenting with moderate to severe UC, especially in those patients who are resistant to steroids or immunosuppressants. 18Early commencement of antiviral would be beneficial in the management of flare of ulcerative colitis.
had been applied in our patient as well.

Figure 1 .
Figure 1.Pre-treatment colonoscopy reviewed of moderate colitis -hemorrhagic mucosal erosions at recto-sigmoid region and descending colon.