Uncommon endoscopic manifestations of cytomegalovirus colitis in an immunocompetent patient

An 81-year-old female with a medical history of hypertension, paroxysmal atrial fibrillation, and hypothyroidism presented with diffuse abdominal pain and distention for 2 weeks. She had experienced a compression fracture of the lumbar spine at home 1 month ago, resulting in her bedridden status and constipation. Abdominal computed tomography revealed a large fecalith in the rectum and pericolic fat stranding of the rectosigmoid colon (Figure 1). Under the initial impression of stercoral colitis, she received empirical antibiotics and laxatives.1, 2 Despite experiencing bowel movements, her abdominal pain and distention failed to be alleviated with antibiotic treatment. Toxin and culture of Clostridium difficile from her stool were negative. A colonoscopy on the 12th day of hospitalization revealed a circumferential ulcer with a mucosal defect and cobblestone-like appearance extending from the upper rectum to the sigmoid colon (Figure 2A,B). The histological report of specimens from biopsies revealed large ovoid nuclei with basophilic intranuclear inclusion bodies in the mesenchymal and endothelial cells (Figure 2C). Immunohistochemical staining was positive for cytomegalovirus (CMV) (Figure 2D). Her serum immunoglobulin M antibodies to CMV were negative, and her CMV viral load was 4860 IU/mL, indicating a reactivated infection. Her symptoms subsided following treatment with ganciclovir. The circumferential ulcer with a mucosal defect and the cobblestone-like appearance of the colon could be caused by an infection of Clostridium difficile, CMV, Mycobacterium tuberculosis, or Crohn's disease.3 Thus, a histologic diagnosis is important. Finally, the histology revealed CMV colitis without cryptitis or volcanic eruption, and the acid-fast staining was negative. CMV colitis usually occurs in immunocompromised patients, with deep ulcers and punched-out ulcers being the most specific endoscopic findings.4, 5 This case, with uncommon endoscopic manifestations, reminds us that CMV colitis should be considered when ulceration or inflammation is identified during colonoscopy. It is important to perform biopsies for histological confirmation. The authors thank the Department of Pathology, Chung Shan Medical University Hospital, Taichung, Taiwan for their support. The authors declare no conflicts of interest. Written informed consent was obtained from the patient.