Cytomegalovirus colitis masquerading as an indeterminate colitis flare-up: Case report and review of the literature

This case report describes a 63-year-old female who presented with severe, refractory lower gastrointestinal bleeding. An initial colonoscopy was inconclusive, and due to ongoing massive bleeding unresponsive to conservative treatment, she underwent a subtotal colectomy. Histopathological examination of the colectomy specimen revealed indeterminate colitis (IC), and she was managed with conventional inflammatory bowel disease (IBD) therapies. However, her symptoms persisted post-surgery, including decreased appetite, weight loss, abdominal pain, and fatigue. Further evaluation revealed active indeterminate IBD associated with cytomegalovirus (CMV) colitis and refeeding syndrome. Sigmoidoscopy confirmed active colitis with CMV inclusions. The patient was treated with antiviral therapy using ganciclovir, aggressive management of refeeding syndrome, and concurrent IBD therapy. She showed significant clinical improvement following this multidisciplinary approach. This case highlights the importance of considering CMV infection, even in immunocompetent individuals with refractory IBD, and demonstrates that antiviral treatment can be critical to recovery when standard therapies fail. It also emphasizes the need to evaluate the role of steroids and biologics in managing IC with CMV coinfection.