A Case of Severe CMV Colitis Complicated with Megacolon and Perforation in an Immunocompetent Prisoner

Aims and Introduction: Cytomegalovirus (CMV) colitis often occurs in immunocompromised patients and those with inflammatory bowel disease, but only occurs occasionally in those without previous medical illness. Here we report on a patient without previous medical illness who presented acutely and was eventually diagnosed as CMV colitis.

Case Presentation: A 44 year old prisoner had a one week history of diarrhea and abdominal pain, and presented in septic shock. Abdominal X-rays and CT scan showed marked colon dilatation. Although he had transient clinical improvement with intravenous Meropenem, he experienced clinical deterioration after 2 weeks, including episodes of acute lower gastrointestinal bleeding. Limited sigmoidoscopy revealed friable mucosa with diffuse ulceration. He then developed colon perforation and required partial colectomy, but died of septic shock shortly after. Histopathological examination of the biopsy and colectomy specimens revealed the diagnosis of CMV colitis.

Discussion: CMV colitis most often presents with diarrhea which can be acute or chronic, and may lead to lower gastrointestinal bleeding. Severe CMV colitis may result in toxic megacolon or perforation. Tissue biopsy for histopathological examination and immunostaining is the gold standard for diagnosis of CMV colitis. Once diagnosed, timely treatment with IV Ganciclovir is recommended.

Conclusion: This case highlights that CMV colitis should be considered in the differential diagnosis of severe colitis with colon dilatation, including in immunocompetent patients. Sigmoidoscopy should be considered in such cases to obtain tissue biopsies to confirm the diagnosis.