Introduction: Cytomegalovirus (CMV) infection in severe ulcerative colitis (UC) is thought to either be the cause or the result of steroid resistant ulcerative colitis. The cause of this discrepancy is due to conflicting study results. These occur because of poor detection techniques for CMV in tissue samples compounded by unclear distinction between the type of inflammatory bowel disease (i.e. Crohn's vs UC) affected in the case description. Our goal is to add to the existing body of evidence of CMV infection in UC towards improving evidence based management and care and also highlight the diagnostic and management conundrum prevailing at this time through the following case.
Case Description/Methods: A 69 year old male presented in the outpatient setting with several months of bloody diarrhea and was found to have UC of the whole colon through colonoscopy. Biopsy results did not find any dysplasia nor granulomata. CMV immunohistochemistry was negative. Patient was on Sulfasalazine for two weeks before he presented for inpatient admission with voluminous bloody diarrhea ongoing for several days. After Clostridioides Difficile (CDiff) testing was negative, steroid therapy was started. After 3 days, steroid resistant disease was determined and patient was transitioned to Infliximab with some initial improvement. He had significant deterioration after 4 days of treatment and was then found to be CDiff positive for which oral Vancomycin was initiated. A flexible sigmoidoscopy was performed, revealing extensive inflammation with spontaneous bleeding and evidence of ulceration. Biopsy results indicated CMV coinfection this time. Intravenous Ganciclovir treatment was initiated. However, patient had no improvement after three days of antiviral therapy and hence underwent colectomy with end ileostomy.
Discussion: Current guidelines recommend treatment with 14 days of Ganciclovir in CMV infection in UC. However, due to conflicting evidence, they do not recommend delaying colectomy until a full course of antiviral medication management is complete. As surgical intervention, especially those resulting in stoma, have significant negative burden on quality of life for patients, it is important to expediently work towards evidence based consensus on treatment and management of this condition. Improving the quality and quantity of clinical data through case reports and series along with better detection techniques for CMV are the first steps towards this goal.
