Introduction
Background
Cytomegalovirus (CMV) is a member of the Herpesviridae family, along with herpes simplex viruses 1 and 2, Epstein-Barr virus, and varicella-zoster virus. It is a double-stranded DNA virus with a protein coat and lipoprotein envelope. Similar to other herpesviruses, CMV is icosahedral and replicates in the host's nucleus. Replication in the host cell typically manifests pathologically with large intranuclear inclusion bodies and smaller cytoplasmic inclusions, and is accompanied by presence of CMV viral particles in the plasma.
Gross specimen of bowel showing ulceration secondary to cytomegalovirus colitis.
Giant cell with inclusion body characteristic of cytomegalovirus colitis.
Between 50% and 80% of the world's population is seropositive for CMV. Initial CMV infection in the immunocompetent host typically is mild and goes undetected clinically. This is followed by a chronic latent state, during which the virus remains present within host cells, but viral proliferation is prevented by host cell-mediated immunity. Failure of immune containment may lead to reactivation with viral proliferation and severe systemic illness. Systemic CMV disease is characterized by fever, pancytopenia, and inflammatory changes in multiple organs including the liver and lungs, and in the retina. Colitis is a frequent manifestation of this acute systemic illness.
Patients are rendered susceptible to systemic CMV disease by treatment with immunosuppressive medications, or by illnesses that reduce cellular immunity, such as human immunodeficiency virus (HIV) infection. Acute systemic illness caused by CMV is particularly common following initial exposure in an immune compromised individual (in particular, in a CMV-negative transplant recipient who receives an organ from a CMV-positive donor).
Pathophysiology
CMV has 3 major patterns of infection.
The first is primary infection, in which a patient who has never been exposed to the pathogen becomes infected, either by contact with another patient who is actively infected or by transfer of blood or tissue from a seropositive individual with latent virus. The second pattern, reactivation, occurs in a patient who is seropositive with a latent virus when the host's immune system becomes compromised. The third, superinfection, occurs when a patient who is CMV-seropositive receives latently infected cells from another patient who is seropositive. The resulting CMV infection is from the latent donor cells, not from the recipient cells.
Regardless of the pattern of infection, resolution of active infection results in a latent state in which CMV persists indefinitely in the host tissues. Viral proliferation is absent, and viral antigen and DNA are undetectable in plasma. If the host's T-cell response becomes compromised by disease or immunosuppressive therapy, latent virus reactivation can occur.
CMV infection can cause a variety of syndromes. Most primary infections in immunocompetent individuals go undetected. Nonspecific fever, sometimes accompanied by pancytopenia, characterizes uncomplicated CMV infection. Severe cases of tissue-invasive CMV disease may produce a bewildering array of clinical syndromes, depending on the particular organs involved.
When the colon becomes affected by tissue-invasive CMV, ulcerative changes can be seen. As the body mounts an inflammatory response, watery diarrhea may begin to develop. As ulcers increase in depth, erosion into blood vessels can cause profuse bloody diarrhea. Over time, inflammatory polyps may develop, which, rarely, may obstruct the colon. Severe inflammation and vasculitis may lead to ischemia and transmural necrosis of the bowel, resulting in perforation and peritonitis.
Frequency
United States
CMV colitis is rare in immunocompetent patients. It occurs in 2-16% of patients who have received solid organ transplants and in 3-5% of patients with HIV infection or acquired immunodeficiency syndrome (AIDS). A study documented CMV infection in 27.3% of patients with steroid-refractory ulcerative colitis and 9.1% of patients with nonrefractory colitis.1
Mortality/Morbidity
- Since the introduction of effective antiviral agents, morbidity and mortality have been reduced.
Race
- No racial predilection has been documented.
Sex
- No sexual predilection is recognized.
Age
- Reports of patients who are not immunocompromised contracting CMV colitis indicate that the illness tends to occur in patients older than 70 years. In immunocompromised patients, CMV can occur at any age, including the newborn period.
Clinical
History
Patients may present with the following symptoms:
- Fever
- Anorexia
- Malaise
- Weight loss
- Dehydration
- Abdominal pain
- Abdominal distention
- Nausea
- Vomiting
- Chronic watery diarrhea
- Bloody diarrhea
- Constipation
- Worsening symptoms of inflammatory bowel disease2
Physical
Patients with CMV colitis may exhibit a wide range of abdominal findings depending on the stage of their disease.
- Abdominal signs are not present early in the disease.
- Tenderness may develop in the descending and sigmoid colon as the bowel becomes more involved.
- Peritoneal signs and fever may be present. If the bowel becomes ischemic or perforates, stigmata of an acute abdomen may develop.
Causes
Any factor that causes a decrease in a patient's immunity increases the risk for CMV colitis.
- Adults older than 70 years, especially if nutritionally depleted
- HIV infection and AIDS
- High- and low-dose steroid therapy and therapy with other immunosuppressive medications
- Transplantation patients (especially patients receiving CMV-positive organs)
- Hemodialysis
- Neoplasia
- Inflammatory bowel disease
- Alcoholism
- Collagen-vascular disease (seems to be related to immunosuppressive therapy)
- Blood transfusions
- Malnutrition
More on Cytomegalovirus Colitis |
 Overview: Cytomegalovirus Colitis |
| Differential Diagnoses & Workup: Cytomegalovirus Colitis |
| Treatment & Medication: Cytomegalovirus Colitis |
| Follow-up: Cytomegalovirus Colitis |
| Multimedia: Cytomegalovirus Colitis |
| References |
| Further Reading |
| Next Page » |
References
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Further Reading
Related eMedicine Topics
- Crohn Disease
- Cytomegalovirus [in the Infectious Diseases section]
- Cytomegalovirus Infection [in the Pediatrics: General Surgery section]
- HIV Disease [in the Infectious Diseases section]
- Infections in the Immunocompromised Host [in the Pediatrics: General Medicine section]
- Inflammatory Bowel Disease
- Ulcerative Colitis
Clinical Trials
- Prevalence of Cytomegalovirus, Epstein Barr Virus and Human Herpes 6 Virus in Inflammatory Bowel Disease
- Study Comparing Cyclosporine With Infliximab in Steroid-refractory Severe Attacks of Ulcerative Colitis
Clinical Guidelines
- ACR Appropriateness Criteria® acute abdominal pain and fever or suspected abdominal abscess. American College of Radiology - Medical Specialty Society. 1996 (revised 2006). 7 pages. NGC:005138
- American Gastroenterological Association Institute medical position statement on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. American Gastroenterological Association Institute - Medical Specialty Society. 2006 Mar. 5 pages. NGC:004873
- ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease. American Society for Gastrointestinal Endoscopy - Medical Specialty Society. 2006 Apr. 8 pages. NGC:004977
- Evidence-based care guideline for cytomegalovirus prophylaxis following solid organ transplants. Cincinnati Children's Hospital Medical Center - Hospital/Medical Center. 2001 Jun 7 (revised 2007 July 6). 15 pages. NGC:006205
- Gastrointestinal complications of HIV. New York State Department of Health - State/Local Government Agency [U.S.]. 2006 Oct. 17 pages. NGC:006477
- Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. 2004 Dec 17 (revised 2009 Apr 10). 207 pages. NGC:007188
Keywords
cytomegalovirus colitis, CMV colitis, CMV, CMV gastrointestinal disease, CMV GI disease, CMV infection, Herpesviridae, herpesvirus, herpes simplex virus, HSV, Epstein-Barr virus, varicella-zoster virus, HIV, AIDS, HIV disease complications,
bloody diarrhea, watery diarrhea, AIDS complications, CMV ulcerative colitis, cytomegalovirus ulcerative colitis, cytomegalovirus UC, steroid-dependent ulcerative colitis, cytomegalovirus infection, cytomegalovirus
