Title : Radiation proctitis with recurrent gastrointestinal bleed complicated by cytomegalovirus: A case report
Abstract:
Abstract:
Cytomegalovirus (CMV) is a well-known DNA virus of the human herpesvirus group that is known to cause a myriad of infections, more commonly in patients who are immunocompromised. Initial infections with this virus are frequently short-lived, presenting in the form a mild mononucleosis-like syndrome, following which this virus remains in a dormant state marked by the presence of antibodies to CMV. However, there are case reports describing CMV colitis in immunocompetent hosts.
We present a case of a patient with multiple episodes of life-threatening gastrointestinal (GI) bleeding secondary to a CMV positive rectal ulcer and CMV colitis after receiving radiation therapy for prostate cancer. An 81-year-old male who presented with large volume hematochezia had relevant past medical history of paroxysmal atrial fibrillation, mechanical aortic valve replacement on coumadin, prostate cancer status-post radiotherapy and previously diagnosed radiation proctitis. This was complicated by a non-healing rectal ulcer status-post argon plasma coagulation with recurrent large volume hematochezia.
Given our patient’s repeated visits with GI bleed and non-healing rectal ulcer, we kept a broad initial differential; including radiation proctitis, rectal malignancy, ischemic colitis, infectious colitis and inflammatory bowel disease. Infectious causes included herpes simplex virus, cytomegalovirus, lymphogranuloma venereum, amebiasis and secondary syphilis.
He had been hospitalized on three prior occasions at our facility over the past 4 months with low hemoglobin, requiring blood transfusions. Flexible sigmoidoscopy during his second hospitalization revealed radiation proctitis and biopsy of a non-healing left-sided rectal ulcer that was positive for CMV, negative for malignancy, and HSV. Follow-up CMV DNA polymerase chain reaction (PCR) was positive with a low viral load and CMV IgM antibody was negative, suggesting that the CMV infection was localized to the ulcer and had not spread systemically.
Initial physical exam revealed temperature of 36.7 degrees Celsius, saturating 96% on room air, blood pressure 180/87 and pulse of 85 beats/min. Frank red blood per rectum was not seen on inspection. Abdomen was soft, non-tender without any guarding, masses or rigidity. Hemoglobin was 7.7g/dL, hematocrit was 24.2% and INR was 2.3. CT abdomen and pelvis revealed an active bleed from the left side of the rectum and proctitis.
The patient had an episode of hematochezia while inpatient and hemoglobin dropped to 6.2, requiring transfusion of 2 units of blood. Embolization of the left middle rectal artery with coil packing was performed the next day by interventional radiology and hemoglobin stabilized. The patient was started on 450mg valganciclovir twice daily as an inpatient to complete a 14-day course for treatment of CMV positive rectal ulcer. Since completion of therapy, there has been no other hospitalization for lower GI bleed.
We present a case of CMV colitis that occurred in a patient diagnosed with prostate cancer, received radiation therapy one year prior, who had neither HIV infection nor medication such as chemotherapy or corticosteroids that could cause immunosuppression. The CMV colitis was complicated by severe GI bleeding, and required antiviral therapy.
Audience Take Away:
- The gastrointestinal manifestations of CMV in immunocompromised patients has already been well established in the literature. However, research regarding its occurrence in otherwise healthy individuals is lacking. The severe, life-threatening complications of CMV disease in immunocompetent patients may not be as rare as previously thought. Antiviral therapy should be taken into consideration as early as possible in patients with severe CMV disease regardless of immune system status.
- We urge clinicians to consider this diagnosis in patients presenting with symptoms consistent with hemorrhagic enteritis, colitis or overt GI bleeding, with special attention paid to patients with risk factors such as extended hospitalizations, acute severe illness, history of radiation therapy and inflammatory bowel disease.
