Cytomegalovirus Colitis Treatment & Management

Updated: Feb 04, 2019
  • Author: Douglas M Heuman, MD, FACP, FACG, AGAF; Chief Editor: BS Anand, MD  more...
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Treatment

Medical Care

Patients with HIV infection

Studies have documented the profound effect of potent antiretroviral therapy on the natural history of infection with human immunodeficiency virus (HIV). Because most patients affected by cytomegalovirus (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. [13]

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. [4, 10] 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. [10] In some patients with steroid-refractory ulcerative colitis with CMV, steroid therapy may be of benefit. [14]

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. [15] 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. [15]

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 greater 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 cytomegalovirus (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 human immunodeficiency virus (HIV) infection.

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Prevention

In cytomegalovirus (CMV)-naive patients receiving solid organ transplants from CMV-positive donors, the risk of CMV disease exceeds 40%. Prophylactic administration of ganciclovir or valganciclovir for 100 days post transplant markedly reduces the incidence of tissue invasive CMV infection. However, after prophylaxis is discontinued, some patients develop delayed CMV disease.

An alternative approach is weekly monitoring of CMV DNA with preemptive antiviral treatment when viremia is detected. The preemptive approach has theoretical appeal, as it may encourage activation of the endogenous immune responses to CMV while arresting infection before tissue invasive disease can develop. Preemption also avoids the cost and toxicity of antiviral medications in those patients who achieve spontaneous immunity to CMV. Prophylaxis versus preemption is currently an area of controversy in the transplant literature.

Prophylaxis is also commonly administered in CMV-seropositive transplant patients during periods when intensified immunosuppression is required for the treatment of acute or chronic rejection.

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