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Cytomegalovirus Colitis Treatment & Management

  • Author: Douglas M Heuman, MD, FACP, FACG, AGAF; Chief Editor: BS Anand, MD  more...
 
Updated: Nov 02, 2015
 

Medical Care

Patients with HIV infection

Studies have documented the profound effect of potent antiretroviral therapy on the natural history of HIV infection. Because most patients affected by CMV colitis have HIV infection, the increasing use of these newer therapies has fortuitously helped the treatment and prevention of CMV colitis.

Patients receiving antiretroviral therapy have shown a decrease in HIV viral load, increased CD4+ lymphocyte counts, decreased hospitalization, and decreased opportunistic infections (eg, CMV colitis). For these patients, aggressive treatment of HIV infection is the key in treating and preventing CMV infection.

Patients who have CMV colitis benefit from antiviral therapy.[9]

Long-term prophylaxis with peroral ganciclovir is considered in patients infected with HIV who have CD4+ lymphocyte counts of less than 50 cells/µL.

Patients with other types of immunosuppressive factors (eg, transplantation, long-term steroid use, renal dialysis)

Because these patients are immunosuppressed by other illnesses or iatrogenic causes, the only treatment is ganciclovir.[7, 3] Discontinuation of steroid or immunosuppressive agents in these patients is discouraged, unless the infection is not responding to antiviral therapy.

Patients who are not immunosuppressed

Treat with antiviral agents.

Limited evidence suggests that targeted therapy with ganciclovir or valganciclovir may be used to manage severe CMV disease in immunocompetent adults.[7]  In some patients with steroid-refractory ulcerative colitis with CMV, steroid therapy may be of benefit.[10]

A study of by Maconi et al indicated that antiviral therapy may aid in maintaining remission in patients with CMV colitis; specifically, those with ulcerative colitis or steroid-dependent/refractory disease. The study involved 38 patients with active CMV colitis, including 30 with ulcerative colitis and eight with Crohn disease. Antiviral therapy was administered to 13 patients; over a 1-year follow-up period, 23% of patients in the antiviral group suffered a clinical relapse requiring new treatment or colectomy, compared with 50% of patients who did not receive antiviral treatment. More specifically, among patients with ulcerative colitis, 77.8% of those who underwent antiviral therapy maintained remission over the 12 months, compared with 45% of patients who were not treated, while among patients with steroid-dependent/refractory disease, 77.8% of those who received antiviral therapy maintained remission, compared with 19.4% of the untreated patients.[11]

Hospitalization

Patients with symptomatic disease should undergo induction therapy with intravenous ganciclovir or intravenous foscarnet. Combination therapy with ganciclovir and foscarnet may be effective if monotherapy fails; however, this is associated with significant toxicity.

Maintenance therapy may be considered, especially in patients who require reinduction for relapse.

Diet and activity

Unless a patient has severe diarrhea, no special diet is needed. Patients with severe diarrhea may require bowel rest until the diarrhea subsides. Parenteral nutritional support may be needed.

No activity restriction is usually required.

Transfer

Patients may be transferred to a skilled nursing facility or equal care provider during treatment, as long as their clinical situation is controlled. Patients with severe CMV colitis should be monitored closely in either an acute-care setting or a regular hospital floor.

Patient monitoring and patient education

Patients should receive routine ophthalmologic screening for CMV retinitis (self-screen for visual acuity and floaters).

Therapy may need to be discontinued in patients infected with HIV who have clinical resolution and CD4+ lymphocyte counts of higher than 100-150 cells/μL.

Patients should be educated about the nature of their disease and the possibility of recurrence; in particular, patients with HIV infection or AIDS should be aware of the possibility of recurrence.

For patient education resources, see HIV/AIDS and HIV Testing.

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Surgical Care

Bowel resection should be considered only in patients with life-threatening ischemia or uncontrolled bleeding.

Patients presenting with signs of peritonitis should undergo immediate laparotomy. Laparotomy may reveal discoloration of the serosa and small perforations.

Patients who undergo resection for perforation should have a diverting stoma, and the incision should be allowed to heal by secondary intention.

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Consultations

Because CMV colitis is usually observed as part of a multisystemic disease, the following consultations should be obtained:

  • Consult an ophthalmologist to evaluate the patient for the presence of CMV retinitis. Patients should be instructed to monitor their vision and report any change in visual acuity or the presence of floaters.
  • Consult a gastroenterologist to aid in diagnosis and treatment.
  • Consult a surgeon for patients who may require bowel resection or for those who develop complications.
  • Infectious disease experts should be consulted to help treat CMV infection and to help exclude underlying HIV infection.
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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, American Gastroenterological Association

Disclosure: Received grant/research funds from Novartis for other; Received grant/research funds from Bayer for other; Received grant/research funds from Otsuka for none; Received grant/research funds from Bristol Myers Squibb for other; Received none from Scynexis for none; Received grant/research funds from Salix for other; Received grant/research funds from MannKind for other.

Coauthor(s)

Vivek V Gumaste, MD Associate Professor of Medicine, Mount Sinai School of Medicine of New York University; Adjunct Clinical Assistant, Mount Sinai Hospital; Director, Division of Gastroenterology, City Hospital Center at Elmhurst; Program Director of GI Fellowship (Independent Program); Regional Director of Gastroenterology, Queens Health Network

Vivek V Gumaste, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association

Disclosure: Nothing to disclose.

Jasmohan S Bajaj, MD, MSc Assistant Professor of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey D Band, MD, FACP, FIDSA Professor of Medicine, Oakland University William Beaumont School of Medicine; Health System Chair, Healthcare Epidemiology and International Medicine, Beaumont Health System; Former Chief of Infectious Diseases, Beaumont Hospital; Clinical Professor of Medicine, Wayne State University School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Deron J. Tessier, MD, and Russell A. Williams, MBBS, to the development and writing of this article.

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. 2005 Jun. 37(6):418-23. [Medline].

  2. Kim YS, Kim YH, Kim JS, Cheon JH, Ye BD, Jung SA, et al. Cytomegalovirus infection in patients with new onset ulcerative colitis: a prospective study. Hepatogastroenterology. 2012 Jun. 59(116):1098-101. [Medline].

  3. Sager K, Alam S, Bond A, Chinnappan L, Probert CS. Review article: cytomegalovirus and inflammatory bowel disease. Aliment Pharmacol Ther. 2015 Apr. 41 (8):725-33. [Medline].

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

  5. Al-Zafiri R, Gologan A, Galiatsatos P, Szilagyi A. Cytomegalovirus complicating inflammatory bowel disease: a 10-year experience in a community-based, university-affiliated hospital. Gastroenterol Hepatol (N Y). 2012 Apr. 8(4):230-9. [Medline]. [Full Text].

  6. Pillet S, Pozzetto B, Jarlot C, Paul S, Roblin X. Management of cytomegalovirus infection in inflammatory bowel diseases. Dig Liver Dis. 2012 Jul. 44(7):541-8. [Medline].

  7. Lancini D, Faddy HM, Flower R, Hogan C. Cytomegalovirus disease in immunocompetent adults. Med J Aust. 2014 Nov 17. 201 (10):578-80. [Medline].

  8. Goodman AL, Murray CD, Watkins J, Griffiths PD, Webster DP. CMV in the gut: a critical review of CMV detection in the immunocompetent host with colitis. Eur J Clin Microbiol Infect Dis. 2015 Jan. 34 (1):13-8. [Medline].

  9. Jones A, McCurdy JD, Loftus EV Jr, Bruining DH, Enders FT, Killian JM, et al. Effects of Antiviral Therapy for Patients with Inflammatory Bowel Disease and a Positive Intestinal biopsy for Cytomegalovirus. Clin Gastroenterol Hepatol. 2014 Oct 2. [Medline].

  10. Shukla T, Singh S, Loftus EV Jr, Bruining DH, McCurdy JD. Antiviral therapy in steroid-refractory ulcerative colitis with cytomegalovirus: systematic review and meta-analysis. Inflamm Bowel Dis. 2015 Nov. 21 (11):2718-25. [Medline].

  11. Maconi G, Lombardini M, Furfaro F, et al. Long-term outcome of inflammatory bowel diseases with cytomegalovirus colitis: effect of antiviral treatment. Eur J Gastroenterol Hepatol. 2014 Oct. 26(10):1146-51. [Medline].

 
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Gross specimen of bowel showing ulceration secondary to cytomegalovirus colitis.
Giant cell with inclusion body characteristic of cytomegalovirus colitis.
 
 
 
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