Background

Cytomegalovirus (CMV) colitis is an inflammation of the colon caused due to the cytomegalovirus. CMV is a member of the Herpesviridae family. 

It is a DNA virus with protein coat and lipoprotein envelope. Initial CMV infection in healthy hosts is usually mild. 

During chronic latent state, viruses remain in host cells, but immune response prevents viral replication. 

Immune failure can cause viral reactivation and severe illness. CMV disease causes fever, pancytopenia, organ inflammation in liver, lungs, and retina. 

Host cell replication results in large nuclear and small cytoplasmic inclusions. CMV causes acute illness in immunocompromised individuals after initial exposure. 

Epidemiology

CMV colitis rare in immunocompetent patients, occurs in 2-16% post solid organ transplants and 3-5% with HIV infection. No racial or sexual predilection is identified. 

CMV infection found in 27.3% with steroid-refractory UC and 9.1% in nonrefractory colitis. CMV colitis in older non-immunocompromised patients may indicate an illness tendency after age 70. 

CMV reactivation prevalence is 4.5% to 16.6% in severe colitis patients up to 25% post-colectomy. 

Anatomy

Pathophysiology

Primary infection occurs when an individual who has never been exposed to a pathogen becomes infected through contact with an actively infected patient or through transfer of blood or tissue. 

Latent virus reactivation in seropositive patient due to weakened immune system. 

Superinfection happens when CMV-seropositive patients get latently infected cells from another seropositive patient causes new infection. 

Severe CMV disease can cause various clinical syndromes based on affected organs. 

Etiology

Causes of CMV colitis are: 

Human immunodeficiency virus infection 

High and low dose steroid therapy 

Transplantation patients 

Hemodialysis 

Inflammatory bowel disease 

Blood transfusions 

Genetics

Prognostic Factors

Proper antiviral treatment and quick diagnosis lead to good prognosis for CMV colitis patients. 

Prognosis in non-immunocompromised patients age-dependent, in >55 years old higher mortality rates noted. 

CMV reactivation in inflammatory bowel disease patients with steroid-refractory colitis. Antiviral agents can help in CMV colitis from reactivation. 

Clinical History

Cytomegalovirus colitis affect individuals of any age group. 

Physical Examination

Abdominal Examination 

Rectal Examination 

Skin and Mucous Membranes assessment 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

For acute presentation: 

High Fever 

Severe Dehydration 

Severe Abdominal Pain 

Profuse Diarrhea 

For chronic presentation: 

Low-Grade or Absent Fever 

Significant Weight Loss 

Mild to Moderate Abdominal Pain 

Chronic Diarrhea 

Differential Diagnoses

Bacterial Infections 

Ischemic Colitis 

Radiation Colitis 

Inflammatory Bowel Disease 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Antiretroviral therapy improves HIV viral load, CD4+ counts, hospitalization, and infections in patients. 

Preventive use of ganciclovir for HIV patients with low CD4 counts. 

Do not stop steroids or immunosuppressants unless infection is unresponsive to antivirals. 

Symptomatic patients need induction therapy with intravenous drugs. 

Advanced therapies used for CMV colitis in HIV patients also aid in treatment and prevention. Close monitoring essential for severe CMV colitis patients. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-non-pharmacological-approach-for-cytomegalovirus-colitis

Bathrooms/washroom should be disinfected regularly to prevent the spread of infection. 

Patient should take diet rich nutrients to support immune function and recovery. 

Patient should maintain proper fluid level to prevent dehydration from diarrhea. 

Patient should do regular exercise to improve overall health. 

Follow techniques such as relaxation exercises and counselling to reduce stress. 

Proper education and awareness about CMV colitis should be provided and its related causes with management strategies. 

Appointments with a gastroenterologist and preventing recurrence of disorder is an ongoing life-long effort. 

Use of Antiviral drugs

Ganciclovir: 

It inhibits CMV replication with competitive inhibition of viral DNA polymerases to cause termination of viral DNA elongation.  

Foscarnet: 

It inhibits activity of pyrophosphate binding site on virus-specific DNA polymerases and reverse transcriptases. 

use-of-intervention-with-a-procedure-in-treating-cytomegalovirus-colitis

Surgery is recommended for severe ischemia and uncontrollable bleeding cases. 

Immediate laparotomy is needed for peritonitis patients with serosa discoloration and perforations. 

use-of-phases-in-managing-cytomegalovirus-colitis

In the initial diagnosis phase, evaluation of medical history, endoscopy and laboratory test to confirm diagnosis. 

Pharmacologic therapy is very effective in the treatment phase as it includes use of antivirals drugs and surgical intervention. 

In supportive care and management phase, patients should receive required attention such as lifestyle modification and rehabilitation. 

The regular follow-up visits with the gastroenterologist are scheduled to check the improvement of patients along with treatment response. 

Medication

Future Trends

Media Gallary

References

Cytomegalovirus Colitis – StatPearls – NCBI Bookshelf (nih.gov)