eMedicine Specialties > Gastroenterology > Colon

Cytomegalovirus Colitis

Author: Douglas M Heuman, MD, FACP, FACG, AGAF, Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Coauthor(s): Jasmohan S Bajaj, MD, MSc, Assistant Professor of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University Medical Center; Vivek V Gumaste, MD, Associate Professor of Medicine, Mt Sinai School of Medicine; Adjunct Clinical Assistant, Mt Sinai Hospital; Director, Division of Gastroenterology, City Hospital Center
Contributor Information and Disclosures

Updated: Jan 5, 2010

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 second...

Gross specimen of bowel showing ulceration secondary to cytomegalovirus colitis.

Gross specimen of bowel showing ulceration second...

Gross specimen of bowel showing ulceration secondary to cytomegalovirus colitis.


Giant cell with inclusion body characteristic of ...

Giant cell with inclusion body characteristic of cytomegalovirus colitis.

Giant cell with inclusion body characteristic of ...

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

References

  1. Maconi G, Colombo E, Zerbi P, et al. Prevalence, detection rate and outcome of cytomegalovirus infection in ulcerative colitis patients requiring colonic resection. Dig Liver Dis. Jun 2005;37(6):418-23. [Medline].

  2. Onyeagocha C, Hossain MS, Kumar A, et al. Latent cytomegalovirus infection exacerbates experimental colitis. Am J Pathol. Nov 2009;175(5):2034-42. [Medline].

  3. Aukrust P, Moum B, Farstad IN, et al. Fatal cytomegalovirus (CMV) colitis in a patient receiving low dose prednisolone therapy. Scand J Infect Dis. 1991;23(4):495-9. [Medline].

  4. Baumgart DC, Targan SR, Dignass AU, et al. Prospective randomized open-label multicenter phase I/II dose escalation trial of visilizumab (HuM291) in severe steroid-refractory ulcerative colitis. Inflamm Bowel Dis. Aug 27 2009;epub ahead of print. [Medline].

  5. Buckner FS, Pomeroy C. Cytomegalovirus disease of the gastrointestinal tract in patients without AIDS. Clin Infect Dis. Oct 1993;17(4):644-56. [Medline].

  6. Dieterich DT, Kotler DP, Busch DF, et al. Ganciclovir treatment of cytomegalovirus colitis in AIDS: a randomized, double-blind, placebo-controlled multicenter study. J Infect Dis. - Busch DF;167(2):278-82. [Medline].

  7. Dieterich DT, Poles MA, Lew EA, et al. Concurrent use of ganciclovir and foscarnet to treat cytomegalovirus infection in AIDS patients. J Infect Dis. May 1993;167(5):1184-8. [Medline].

  8. Drew WL. Cytomegalovirus infection in patients with AIDS. J Infect Dis. Aug 1988;158(2):449-56. [Medline].

  9. Drew WL. Diagnosis of cytomegalovirus infection. Rev Infect Dis. Jul-Aug 1988;10 Suppl 3:S468-76. [Medline].

  10. Esforzado N, Poch E, Almirall J, et al. Cytomegalovirus colitis in chronic renal failure. Clin Nephrol. May 1993;39(5):275-8. [Medline].

  11. Falagas ME, Griffiths J, Prekezes J, Worthington M. Cytomegalovirus colitis mimicking colon carcinoma in an HIV-negative patient with chronic renal failure. Am J Gastroenterol. Jan 1996;91(1):168-9. [Medline].

  12. Frager DH, Frager JD, Wolf EL, et al. Cytomegalovirus colitis in acquired immune deficiency syndrome: radiologic spectrum. Gastrointest Radiol. 1986;11(3):241-6. [Medline].

  13. Galiatsatos P, Shrier I, Lamoureux E. Meta-analysis of outcome of cytomegalovirus colitis in immunocompetent hosts. Dig Dis Sci. Apr 2005;50(4):609-16. [Medline].

  14. Harbison MA, De Girolami PC, Jenkins RL, Hammer SM. Ganciclovir therapy of severe cytomegalovirus infections in solid-organ transplant recipients. Transplantation. Jul 1988;46(1):82-8. [Medline].

  15. Henderson JR. Use of ganciclovir in the treatment of cytomegalovirus infections. Br J Clin Pract. Jul 1989;43(7):233-7. [Medline].

  16. Kambham N, Vij R, Cartwright CA, Longacre T. Cytomegalovirus infection in steroid-refractory ulcerative colitis: a case-control study. Am J Surg Pathol. Mar 2004;28(3):365-73. [Medline].

  17. Kanda Y, Yamashita T, Mori T, et al. A randomized controlled trial of plasma real-time PCR and antigenemia assay for monitoring CMV infection after unrelated BMT. Bone Marrow Transplant. Dec 7 2009;epub ahead of print. [Medline].

  18. Korzets A, Zevin D, Ori Y, et al. Elevated serum alkaline phosphatase levels in a renal transplant patient precede colitis. Transpl Infect Dis. Sep 2006;8(3):157-60. [Medline].

  19. Loftus EV Jr, Alexander GL, Carpenter HA. Cytomegalovirus as an exacerbating factor in ulcerative colitis. J Clin Gastroenterol. Dec 1994;19(4):306-9. [Medline].

  20. Maiorana A, Torricelli P, Giusti F, Bellini N. Pseudoneoplastic appearance of cytomegalovirus-associated colitis in nonimmunocompromised patients: report of 2 cases. Clin Infect Dis. Sep 1 2003;37(5):e68-71. [Medline].

  21. McCune TR, Nylander WA, Van Buren DH, et al. Colonic screening prior to renal transplantation and its impact on post- transplant colonic complications. Clin Transplant. Apr 1992;6(2):91-6. [Medline].

  22. Orloff JJ, Fine MJ, Rihs JD. Acute cardiac tamponade due to cardiac actinomycosis. Chest. Mar 1988;93(3):661-3. [Medline].

  23. Orloff JJ, Saito R, Lasky S, Dave H. Toxic megacolon in cytomegalovirus colitis. Am J Gastroenterol. Jul 1989;84(7):794-7. [Medline].

  24. Rene E, Marche C, Chevalier T, et al. Cytomegalovirus colitis in patients with acquired immunodeficiency syndrome. Dig Dis Sci. Jun 1988;33(6):741-50. [Medline].

  25. San Juan R, Yebra M, Lumbreras C, et al. A new strategy of delayed long-term prophylaxis could prevent cytomegalovirus disease in (D+/R-) solid organ transplant recipients. Clin Transplant. Sep-Oct 2009;23(5):666-71. [Medline].

  26. Sommadossi JP, Bevan R, Ling T, et al. Clinical pharmacokinetics of ganciclovir in patients with normal and impaired renal function. Rev Infect Dis. Jul-Aug 1988;10 Suppl 3:S507-14. [Medline].

  27. Spiegel JS, Schwabe AD. Disseminated cytomegalovirus infection with gastrointestinal involvement. The role of altered immunity in the elderly. Am J Gastroenterol. Jan 1980;73(1):37-44. [Medline].

  28. Teixidor HS, Honig CL, Norsoph E, et al. Cytomegalovirus infection of the alimentary canal: radiologic findings with pathologic correlation. Radiology. May 1987;163(2):317-23. [Medline].

  29. Wada Y, Matsui T, Matake H, et al. Intractable ulcerative colitis caused by cytomegalovirus infection: a prospective study on prevalence, diagnosis, and treatment. Dis Colon Rectum. Oct 2003;46(10 Suppl):S59-65. [Medline].

  30. Whitley RJ, Jacobson MA, Friedberg DN, et al. Guidelines for the treatment of cytomegalovirus diseases in patients with AIDS in the era of potent antiretroviral therapy: recommendations of an international panel. International AIDS Society-USA. - Feinberg J. May 11 1998;158(9):957-69. [Medline].

Further Reading

Related eMedicine Topics

Clinical Trials

Clinical Guidelines

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

Contributor Information and Disclosures

Author

Douglas M Heuman, MD, FACP, FACG, AGAF, Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association
Disclosure: Nothing to disclose.

Coauthor(s)

Jasmohan S Bajaj, MD, MSc, Assistant Professor of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University Medical Center
Disclosure: Nothing to disclose.

Vivek V Gumaste, MD, Associate Professor of Medicine, Mt Sinai School of Medicine; Adjunct Clinical Assistant, Mt Sinai Hospital; Director, Division of Gastroenterology, City Hospital Center
Vivek V Gumaste, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey D Band, MD, Clinical Professor of Medicine, Wayne State University School of Medicine; Director, Division of Infectious Diseases and International Medicine, William Beaumont Hospital Corporation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

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