Fatal cytomegalovirus (CMV) colitis in a patient receiving low dose prednisolone therapy

[Cytomegalovirus ileitis in a non-immunocompromised old patient: a case report]

INTRODUCTION

Cytomegalovirus ileitis occurs rarely in immunocompetent subjects.

CASE REPORT

An 88-year-old woman presented with severe pain located in right iliac fossa. Biological tests showed an increase in C-reactive protein and neutrophils. Colonoscopy revealed a severely ulcerated and inflamed terminal ileal mucosa. Histopathological analysis of biopsies showed a typical cytopathic effect with ballooned cells and intranuclear inclusions, confirmed by positive immunological marking with anti-cytomegalovirus antibodies. Cytomegalovirus polymerase chain reaction in the plasma showed positive activity. The patient was successfully treated with valganciclovir.

CONCLUSION

The predominant or isolated ileal location of cytomegalovirus infection should be known, especially in the elderly because aging could be a risk factor.

Fluocinolone acetonide implant (Retisert) for chronic cystoid macular edema in two patients with AIDS and a history of cytomegalovirus retinitis

PURPOSE

To report the authors' experience using fluocinolone acetonide (Retisert) to treat cystoid macular edema (CME) resulting from immune recovery uveitis (IRU) in 2 acquired immunodeficiency syndrome (AIDS) patients with a history of cytomegalovirus (CMV) retinitis.

DESIGN

Interventional case series.

METHODS

Medical records were reviewed of 2 patients who received Retisert implantation in 3 eyes for IRU-associated inflammation and CME. Suppression of CMV disease was achieved with oral medication in one patient and with simultaneous implantation of a ganciclovir implant in the other patient.

RESULTS

After Retisert implantation in 3 eyes in AIDS patients on HAART, improvement in CME was seen in 2 eyes. No CMV reactivation was detected during the several-month follow-up period.

CONCLUSIONS

Retisert may be an effective treatment for CME in AIDS patients with IRU reactivation and a history of CMV retinitis.

CMV enteritis causing massive intestinal hemorrhage in an elderly patient

Background. Cytomegalovirus (CMV) disease is rare in previously immunocompetent patients. We report a case of CMV enteritis complicated by massive intestinal bleeding. Case History. A 72-year-old immunocompetent patient was admitted for diarrhea and abdominal pain. Aspecific pattern of duodenitis was found at abdomen computed tomography and on biopsies during endoscopy. A diagnosis of vasculitis was suspected on the basis of the clinical and biological course (skin lesions, arthralgias, proteinuria, low complement C3 and C4 fractions, etc.) and pulse steroid therapy was prescribed. The patient developed multiple episodes of intestinal bleeding with shock and required urgent laparotomy. Jejunitis due to CMV vasculitis was proven by histological examination of the operative specimen. Treatment with ganciclovir was initiated. No bleeding recurrence was noted. No other lesions from CMV infection were observed. The patient died from unrelated complications. Discussion. CMV enteritis is a rare cause of intestinal bleeding particularly in previously immunocompetent patients. Aging could be accompanied by a relative immune weakness and specific antiviral therapy seems to be indicated.

Acute cytomegalovirus infection associated with the onset of inflammatory bowel disease

A 29-year-old man was admitted with high-grade fever, crampy abdominal pain, and watery diarrhea that had persisted for 2 weeks before his admission. Symptomatic treatment (acetaminophen only) was of no benefit. On physical examination, there was diffuse abdominal tenderness. Laboratory tests showed a leukomoid reaction with atypical lymphocytosis, and serology tests revealed acute cytomegalovirus infection. Abdominal computed tomography and colonoscopy revealed an inflammatory process involving the large intestine. On histologic examinations of intestinal biopsy samples, there was an active inflammation with no inclusion bodies. The patient was treated with ganciclovir with only mild improvement. Adding 5-aminosalicylic acid caused little further improvement. Repeated colonoscopy performed 2 months later showed severe chronic ulcerative colitis. Only the addition of systemic steroids caused complete resolution of the symptoms. On review of the literature (Medline search for cytomegalovirus colitis in immunocompetent patients), 18 cases were found. On follow-up, 10 of these patients were found to have inflammatory bowel disease.

Corticosteroid Therapy in an Alphaviral Arthritis

BACKGROUND

: Corticosteroid use during acute viral arthritis is considered to be contraindicated as a result of the risk of immunosuppression causing enhanced infection and disease exacerbation.

OBJECTIVES

: The objective of this study was to analyze the effect of oral corticosteroid therapy on symptoms of the viral arthritic disease, Ross River virus disease (RRVD).

METHODS

: Patients with RRVD were enrolled in 2 prospective longitudinal studies. Medications and comorbidities were recorded and the patients' health was assessed using 2 validated quality-of life-questionnaires, the Comparison of Clinical Health Assessment Questionnaire (CLINHAQ) and the Medical Outcomes Study Short Form (SF-36).

RESULTS

: Six patients taking corticosteroids showed no exacerbation of RRVD compared with patients not taking steroids. The CLINHAQ Functional Disability Index also indicated that corticosteroid users recovered faster compared with patients using nonsteroidal antiinflammatory drugs.

CONCLUSION

: Conventional concern that corticosteroid treatment will exacerbate disease appears unjustified for alphaviral arthritides once serodiagnosis has demonstrated antiviral immunity.

Self-limited colitis during the course of rubella and cytomegalovirus infection in an immunocompetent adult

We report a case of self-limited colitis in cytomegalovirus (CMV) infection in an immunocompetent adult. A 22-year-old man developed a high fever and diarrhea. Laboratory data revealed an increased number of lymphocytes and liver damage. Enzyme immunoassays for anti-virus antibodies revealed that the patient was recently infected with CMV and rubella. Colonoscopy revealed severe erosive and edematous mucosa that resembled ulcerative colitis (UC). The symptoms, laboratory data and colonoscopic findings improved without any medical treatment. This case indicates that UC-like self-limited colitis can occur in an immunocompetent individual during the course of CMV infection.

[Acute cytomegalovirus (CMV) recto-colitis mimicking rectal carcinoma without apparent cause of immunodeficiency]

Cytomegalovirus (CMV) infection of the gastrointestinal tract occurs mainly in immunosuppressed patients. We report here the case of a 76-Year-old woman, without obvious cause of immunosuppression, who developed severe proctitis. The clinical course was favourable with ganciclovir therapy. In the absence of controlled data in the field of CMV intestinal infections in immunocompetents, we discuss the potential benefit of an antiviral therapy in those patients who do not recover rapidly and spontaneously.

Disseminated cytomegalovirus disease as a cause of prolonged fever in a bullous pemphigoid patient under systemic steroid therapy

We present the first reported case of disseminated cytomegalovirus (CMV) in association with prednisone therapy in bullous pemphigoid (BP). A 66-year-old black male patient was admitted to our hospital presenting cutaneous pruritic lesions represented by tense blisters, with serous content on the arms, abdomen and legs. Laboratory findings confirmed the diagnosis of BP. After two weeks of prednisone therapy, the patient developed prolonged fever, which was caused by CMV disseminated disease, with prompt clinical recovery after ganciclovir administration.

Reactivation of CMV retinitis after treatment with subtenon corticosteroids for immune recovery uveitis in a patient with AIDS

We present the case of an HIV-infected patient who developed reactivation of CMV retinitis after a local steroid injection for the treatment of immune recovery uveitis. He responded promptly to reinduction with ganciclovir and recovered. To our knowledge this is the first case of CMV retinitis reactivation in an HIV-infected patient receiving steroids for immune recovery uveitis.

Outcome of cytomegalovirus infections in patients with inflammatory bowel disease

OBJECTIVE

The aim of this study was to determine the outcome of cytomegalovirus (CMV) infections complicating the course of inflammatory bowel disease (IBD).

METHODS

The records and clinical courses were reviewed for all IBD patients who were evaluated at the IBD Center of the Cedars-Sinai Medical Center and who developed CMV infection.

RESULTS

Ten patients with severe, medically refractory IBD (five ulcerative colitis, three Crohn's colitis, and two indeterminate colitis) developed CMV infection. All but two were hospitalized with exacerbation of their underlying disease and were receiving immunosuppressive treatment with steroids, thiopurines, and/or cyclosporine at the time CMV infection was recognized. Eight patients had documented colonic CMV (one had concurrent upper GI tract involvement), one developed interstitial CMV and Pneumocystis carinii pneumonia, and one developed primary CMV mononucleosis. Prompt treatment with ganciclovir and withdrawal of immunosuppressive treatment resulted in gradual improvement and induction of remission of the underlying IBD in five patients. The patient with concomitant CMV and P. carinii pneumonitis died. In two patients, treatment with ganciclovir did not alter the clinical course of their IBD, and one of them underwent colectomy. In one patient CMV was found on the resected colonic specimen. One patient with primary CMV infection responded also to ganciclovir treatment.

CONCLUSIONS

CMV infection may aggravate the course of seemingly refractory IBD in patients who either fail to respond or experience worsening of symptoms despite immunosuppressive therapy. Expedient evaluation, prompt treatment intervention with ganciclovir, and withdrawal of immunosuppressive treatment may avoid complications and mortality. This regimen leads to improvement of the underlying IBD in most patients.

Cytomegalovirus colitis in the immunocompetent host: an overview

This paper describes 2 immunocompetent patients with cytomegalovirus colitis and reviews all previously reported cases (n = 13). Affected patients were generally older (69.13+/-15.62 y-old) with probable reactivation (n = 8) or younger (43.86+/-19.73 y-old) with probable primary infection (n = 7). The onset of illness was found to be hospital-associated in 4 (50.0%) reactivation cases and 1 (14.3%) primary case. Presenting manifestations included diarrhoea (86.7%), fever (80.0%), gastrointestinal bleeding (66.7%) and abdominal pain (60.0%). Endoscopy showed erosive colitis with multiple (n = 11; 73.3%) or single ulcers (n = 2, 13.3%); biopsy was diagnostic in 12/13 (92.3%) patients. Complications included massive haemorrhage (13.3%), toxic megacolon (13.3%), perforation (13.3%) and protracted inflammatory bowel disease (20.0%; exclusively in primary-infection). The mortality rate was 26.7%. Antiviral-agents were given in 8 (53.3%) cases; assessment of treatment-efficacy was not possible. In conclusion, cytomegalovirus colitis in the immunocompetent-host is a rare but potentially severe erosive disease with significant morbidity. It may occur during primary infection or reactivation; the diagnosis requires careful histopathological examination and the benefit of antiviral-therapy is unknown.

Cytomegalovirus pneumonia in a patient with breast cancer on chemotherapy: case report and review of the literature

Cytomegalovirus (CMV) pneumonia in the setting of non-transplantation patients is a rarity. We present a case of CMV pneumonitis in a woman with stage IV breast cancer, with brain metastases, receiving both chemotherapy and systemic corticosteroids. A review of the literature reveals this as a unique case. Potential viral etiologies should therefore be considered in cancer patients with pneumonia receiving non-transplantation chemotherapy-regimens, particularly if steroids are a component of their therapy.

Cytomegalovirus colitis in immunocompetent individual

A woman with peripheral vascular disease developed cytomegalovirus colitis following repair of abdominal aortic aneurysm. Cytomegalovirus colitis developing in an immunocompetent individual may be caused by a breach in the integrity of the mucosal lining of the colon from various causes and should alert the clinician to explore these causes in order to provide effective care.

Toxic megacolon caused by cytomegalovirus colitis in a multiply injured patient

Cytomegalovirus (CMV) colitis is a rare event that has been described mainly in immunocompromised patients with immunosuppressive medication or HIV infection. An association with severe trauma has not been described previously. We report a formerly healthy, multiply injured 75-year-old male who subsequently developed what appeared to be pseudomembranous colitis. By the time the diagnosis of toxic megacolon on the basis of CMV colitis was established, he had succumbed to multiple organ failure. Whenever pseudomembranous colitis is clinically suspected but not confirmed in a critically ill formerly healthy patient, CMV colitis should be excluded. Once the diagnosis is confirmed, generous resection of all affected colon is mandatory in view of the limited benefit of antiviral therapy in CMV-induced toxic megacolon.