Letters to the Editor

1130-0108/2015/107/2/117-119Revista española de enfeRmedades digestivasCopyRight © 2015 aRán ediCiones, s. l.

Rev esp enfeRm dig (MadridVol. 107, N.º 2, pp. 117-119, 2015

Lethal pseudomembranous colitis in an immunocompetent patient

Key words: Pseudomembranes. Colitis. Cytomegalovirus. Immu-nocompetence. Infection. Severe disease. Surgery.

Dear Editor,

The most common etiology of diarrhea in hospitalized patients is Clostridium difficile (CD). This bacterium can cause pseudo-membranous colitis (PC), although there are other agents that also can produce this illness, such as cytomegalovirus (CMV) that, occasionally, can affect immunocompetent patients.

We present a case of severe pseudomembranous colitis by CMV in an immunocompetent patient, after a clean elective sur-gery for ovarian cyst.

Case report

A 69-year-old woman, who underwent laparoscopic left oopho-rectomy for benign ovarian cyst 6 days before, without requiring prophylactic antibiotherapy. She was readmitted to the hospital be-cause of diarrhea initiated the first postoperative day.

The CT scan showed colonic dilation and inflammatory changes in the sigma and rectum wall (Fig. 1). Flexible sig-moidoscopy demonstrated pseudomembranes and ulcerations in the mucous membrane. It was oriented as a PC (with compatible biopsies) establishing treatment with metronidazole. The detec-tion in stool samples of toxin A and B for CD was negative as well as the stool culture and serology for HIV.

Because of a torpid evolution with vomiting and megaco-lon without toxaemia, she was urgently operated and a subtotal colectomy with ileostomy was carried out, twelve days after admission.

In the postoperative period, she was admitted to the Intensive Care Unit needing vasoactive drugs due to a multiple organ fail-ure and treated with piperazilin-tazobactam.

On the 5th day, she became hemodynamically unstable due to upper gastrointestinal hemorrhage and signs of ischemia in the ileostomy. The upper endoscopy showed a friable, necrot-ic and ulcerated mucosa from the esophagus to the duodenum. The results of the surgical specimen (Fig. 2D) reported pseu-domembranous colitis with inclusion bodies (Fig. 2) (immuno-histochemical technique) (1) (Fig. 2C), treated with foscarnet but the patient developed a multisystem failure dying the eighth day. The initial sigmoidoscopy biopsies were reviewed without evidence of inclusion bodies.

Fig. 1. CT findings: Thickened rectosigmoid wall with increased contrast enhanced.

118 LETTERS TO THE EDITOR Rev esp enfeRm Dig (maDRiD)

Rev esp enfeRm Dig 2015; 107 (2): 117-119

Discussion

Although in 96-100 % of the cases of PC the cause is CD (2), it also can be caused by other agents, like CMV.

The clinical spectrum ranges from a simple diarrhea to a ful-minant colitis with a mortality rate of up to 80 % (3).

Its diagnosis, in addition to the sigmoidoscopy, involves the search for the causative agent by stool cultures, serology… Nowadays, it has been using the CT scan as an initial comple-mentary test because of its quick results. Typical findings are dilation and thickening of the colonic wall, “sign of the accor-dion” and ascites.

In an immunocompetent host, CMV infection is usually mild but severe cases have also been described (4,5) in immunocom-

petent patients, although they usually are elderly, with comor-bidity (6) and/or underlying intestinal inflammatory illness.

Although CMV can affect any part of the gastrointestinal tract, the most frequent affected are colon and rectum (7-9). Common endoscopic findings are erosions and ulcerations (4,8), but it has also been described pseudomembranes in 2 % case (2,10)

CMV colitis may be complicated with massive hemorrhage, toxic megacolon (7)..., requiring surgery and the best technical election is subtotal colectomy with ileostomy.

The possibility of a specific treatment is hindered by usual late diagnosis. Furthermore, the use of ganciclovir and foscarnet is controversial in the immunocompetent subject due to their toxicity.

Fig. 2. A. Hematoxylin-eosin stain shows deep ulcerations and pseudomembranes in colon tissue (narrow). B. Enlarged cells with viral inclusion bodies in a pseudomembrane. The microscopic description given to these cells is most commonly an “owl’s eye,” a large nucleus containing a purple intranuclear inclusion surrounded by a brighter halo. C. Inclusion bodies (brown) visualized by immunohistochemistry. D. Macroscopic image of the surgical specimen showing mucosal areas of hemorrhage and ischemia.

A

C

B

D

Vol. 107, N.º 2, 2015 LETTERS TO THE EDITOR 119

Rev esp enfeRm Dig 2015; 107 (2): 117-119

Cristina Gas-Ruiz1, Susana Eugenia Ros-López1, Felip Vilardell-Villella2, Carmen Mias-Carballal1,

Rafael Villalobos-Mori1, Mari Cruz de-la-Fuente-Juárez1, Juan Antonio Baena-Fustegueras1

and Jorge Juan Olsina-Kissler1

Departments of 1General Surgery and 2Pathology. Hospital Universitario Arnau de Vilanova. Lleida, Spain

References

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2. Orellana A, Salazar E. Colitis pseudomembranosa asociada al uso de antibióticos. Revisiones bibliográficas. Acta Odontol Venezolana 2009;47:1-5.

3. Greenstein AJ, Byrn JC, Zhan LP, Swedish KA, Jahn AE, Divino C. Risk factors for the development of fulminant Clostridium difficile colitis. Surgery 2007;143:623-9.

4. Seo TH, Kim JH, Ko SY, Jong SN, Lee SY, Sung IK, et al. Cytomegal-ovirus colitis in immunocompetent patients: A clinical and endoscopic study. Original Paper. Hepatogastroenterology 2012;59:2137-41.

5. Rafailidis PI, Mourtzoukou EG, Varbobitis IC, Falagas ME. Severe cytomegalovirus infection in apparently immunocompetent patients: A systematic review. Review. Virol J 2008;5:47.

6. Kurtz M, Morgan M. Concomitant Clostridium difficile colitis and cytomegalovirus colitis in an immunocompetent elderly female. BMJ Case Rep 2012 Dec Doi: 10.1136/bcr-2012-007273.

7. Dinesh BV, Selvaraju K, Kumar S, Thota S. Cytomegalovirus-induced stricture presenting as acute intestinal obstruction in an immunocompe-tent adult. BMJ Case Rep Published online: 2013 Sep 10 Doi: 10.1136/bcr-2013-200944.

8. Galiatsatos P, Shrier I, Lamoureux E, Szilagyi A. Meta-analysis of outcome of cytomegalovirus colitis in immunocompetent hosts. Dig Dis Sci 2005;50:609-16.

9. Tejedor MA, Velasco A, Fernández A, Piñero MC, Calderón R, Prieto AB et al. Ileítis por citomegalovirus en paciente inmunocompetente. Rev Esp Enferm Dig 2011;103:154-6.

10. Nomin N, Telisinghe PU, Chong VH. Cytomegalovirus colitis in immu-nocompetent patients. Case Report. Singapore Med J 2011;52:e170-2.