S5105 CMV Colitis Presenting as Inflammatory Polyposis in a Patient With Common Variable Immunodeficiency

Introduction: Common variable immunodeficiency (CVID) is a genetic disorder characterized by decreased immunoglobulin levels, predisposing individuals to recurrent infections. The gastrointestinal tract is a common site of involvement, with manifestations ranging from infectious colitis to, in rare cases, inflammatory polyposis. Cytomegalovirus (CMV) colitis, primarily seen in immunocompromised hosts, has rarely been associated with inflammatory polyps. We present an unusual case of a middle-aged woman with CVID who developed CMV colitis with numerous inflammatory polyps, requiring intravenous antiviral therapy after oral treatment failure. Case Description/Methods: A 45-year-old woman with CVID, interstitial lung disease, pulmonary hypertension, and chronic hypoxemic respiratory failure presented with several months of 15-20 episodes of bloody diarrhea daily and microcytic anemia. A colonoscopy at an outside facility revealed inflammatory polyps, with biopsies showing CMV inclusions. She was not treated for CMV at that time. Repeat colonoscopy months later revealed numerous inflammatory polyps throughout the colon. Pathology again showed CMV inclusions consistent with CMV colitis. She was referred to Infectious Disease and started on oral valganciclovir. After 5 days, she experienced worsening diarrhea (30-50 times/day) and weight loss. She was advised to go to the Emergency Department, where labs showed elevated ESR (57 mm/hr), C-reactive protein (2.5 mg/dL), CMV viral load (75.6 IU/mL), and CMV DNA (899 IU/mL). She was admitted and treated with 4 days of intravenous (IV) ganciclovir, resulting in significant symptom improvement. She was discharged on oral valganciclovir for 3 weeks. CMV DNA became undetectable after 1 week of treatment and has remained negative since. Discussion: In immunocompromised patients like those with CVID, CMV can cause significant GI disease, including ulceration, diarrhea, hematochezia, and, rarely, inflammatory polyps. Oral valganciclovir is the standard treatment for CMV and typically is as efficacious as IV ganciclovir. However, in patients with significant GI involvement, mucosal damage may impair absorption. This patient’s severe diarrhea, weight loss, and lack of response to oral therapy indicated a component of malabsorption. IV ganciclovir, which bypasses the gut, led to clinical improvement and viral clearance. This case underscores the importance of early recognition and appropriate parenteral treatment in immunocompromised patients with CMV colitis and suspected malabsorption.