Age and Ageing Advance Access originally published online on January 18, 2006
Age and Ageing 2006 35(2):198-200; doi:10.1093/ageing/afj038
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Cytomegalovirus colitis—an unusual cause for diarrhoea in an elderly woman
1 Department of Health Care for the Elderly, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
2 Histopathology Department, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
Address correspondence to: M. R. Lockwood. Tel: (+44) 114 2714970, Fax: (+44) 114 2715981. Email: rosielockwood{at}aol.com
Abstract
Background: clinically apparent cytomegalovirus (CMV) disease is uncommon in the immunocompetent host, despite the high seroprevalence rate of CMV in the general population.
Case report: here, we report the case of CMV colitis in an immunocompetent elderly woman who developed a large pulmonary embolism during her illness.
Discussion: the diagnosis of CMV colitis is made on histological examination of biopsy specimens obtained at sigmoidoscopy or colonoscopy. Extensive CMV disease can be accompanied by vascular thrombosis.
Keywords: elderly, cytomegalovirus, colitis, thrombosis
A 64-year-old lady was admitted with a 6-week history of nausea and diarrhoea. Her medical history included hypertension, paroxysmal supraventricular tachycardia, cerebrovascular disease and a posterior inferior cerebellar artery aneurysm.
On admission, her clinical examination was normal. Investigations revealed a raised white cell count [14.4 x 109/l (normal 3.5–9.5)], raised C-reactive protein [42 mg/l (normal 0–10)] and raised total bilirubin [26 µM/l (normal 1–24)] and aspartate aminotransferase [79 IU/l (normal 15–41)]. Stool cultures were negative. Flexible sigmoidoscopy revealed an inflamed rectum, and biopsies were taken. She developed a hospital-acquired pneumonia 9 days after admission and was treated with intravenous meropenem. On day 12, she became more breathless and hypoxic. Computerised tomographic (CT) pulmonary angiogram confirmed the presence of large, bilateral pulmonary emboli. She was hypotensive, requiring inotropic support, and was anticoagulated with intravenous heparin. She made a good recovery and was stabilised on warfarin.
The rectal mucosal biopsy showed active chronic inflammation with local erosion of the surface epithelium, associated with distorted crypts and a granuloma in the lamina propria. Individual enlarged histiocyte-type cells with prominent nucleoli were found infiltrating the lamina propria (Figure 1). These were also detected immunohistochemically with an anti-cytomegalovirus (CMV) monoclonal antibody. These features were regarded to be consistent with CMV-associated colitis. CMV infection was confirmed with polymerase chain reaction (PCR) performed on paraffin sections and blood.
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No cause for immunosuppression was apparent. She was treated with intravenous ganciclovir and then with oral valganciclovir for 21 days. A 3-month maintenance course of valganciclovir followed. Her diarrhoea settled. She underwent a brief period of rehabilitation before discharge home.
CMV colitis is an uncommon cause of diarrhoea in the older adult, despite the high seroprevalence of CMV in the general population (40–70% of adults in higher socioeconomic groups in developed countries and up to 90% of adults in lower socioeconomic groups and developing countries [1]). CMV colitis is more commonly seen in the immunosuppressed, where it usually represents virus reactivation. A handful of cases with CMV colitis in the immunocompetent have been described in the literature [2, 3]. Mortality rate was 31.8%, with patients over 55 faring significantly worse than the younger individuals. Most cases were diagnosed on sigmoidoscopy.
This patient also suffered extensive pulmonary embolism (PE). CMV is found in the endothelium of most organs during acute infection [4], although the mechanism by which vasculopathy occurs is not known. It has been implicated in thromboembolic disease and other vascular events in the immunocompromised population. There is an association between CMV, venous thromboembolism and human immunodeficiency virus (HIV) [5]. Hepatic artery thrombosis following liver transplant is more likely if a CMV-negative host receives a CMV-positive organ [6]. CMV infection after a heart transplant is associated with accelerated atherosclerosis [7]. In the immunocompetent, CMV is thought to play a role in restenosis after coronary artery angioplasty [8]. Vascular thrombosis in acute CMV infection in the immunocompetent has been reported in 11 cases [9].
The causative link between CMV and thromboembolism is not clear. Owing to the high seroprevalence rates, CMV may be an innocent bystander to these events. Our patient also had other risk factors for PE, such as hospital admission causing immobility and a severe hospital-acquired pneumonia. Furthermore, we would not have made the diagnosis of CMV colitis in our patient without sigmoidoscopy. If other causes of diarrhoea such as drugs or common infections are ruled out by stool culture, sigmoidoscopy and biopsy should be considered as the next line of investigation.
- CMV colitis is a rare cause of diarrhoea in the elderly.
- The diagnosis can usually be made on biopsy at sigmoidoscopy, so this test should be considered in patients who have culture-negative diarrhoea that fails to settle.
- CMV infection may be a risk factor for venous thromboembolism and prophylaxis of this should be considered.
None.
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