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BLOG: 93-year-old male with abdominal pain and distention
Colin Smith, MD, is currently a third year gastroenterology and hepatology fellow at Thomas Jefferson University Hospital. He received a BA from Kenyon College in Gambier, Ohio. He then attended medical school at Jefferson Medical College in Philadelphia, and completed his residency in internal medicine at Thomas Jefferson University Hospital. He looks forward to practicing gastroenterology in the Philadelphia area.
Case
The patient is a 93-year-old with a history of adenocarcinoma of the colon status-post sigmoidectomy ten years prior who presents to the Thomas Jefferson University Hospital emergency department (ED) with abdominal pain and distention. A week prior he was evaluated at another ED and was treated for a fecal impaction with manual disimpaction. In our ED he noted increased abdominal girth without passage of stool or flatus since discharge from the outside ED. He denied fevers, chills, SOB, or chest pain, and had not noticed any recent weight loss, melena, or hematochezia. A rectal tube was placed, resulting in significant output of stool and gas and decreased distention and pain.
Colin Smith
His past medical history included coronary artery disease, H. pylori-associated peptic ulcer disease treated with triple-therapy, untreated prostate cancer, and colon adenocarcinoma (Stage IIA [T3N0M0]) diagnosed 10 years ago. His past surgical history included a two-vessel coronary artery bypass graft, as well as a sigmoidectomy with coloproctostomy for the colon cancer 10 years prior to presentation. His family history and social history were unremarkable.
The patient last underwent colonoscopy five years ago. The preparation was poor. Oozing ulcerations were noted at 40 cm from the anal verge, and biopsies revealed focal ulceration and granulation tissue without evidence of neoplasia.
On exam, his vital signs were normal. His abdomen was moderately distended and tympanic without tenderness. His bowel sounds were active and “tinkling.” There were no palpable masses or organomegaly. The remainder of the exam was unremarkable.
Laboratory Data and Imaging
His complete blood count, metabolic panel, electrolytes, and liver function tests were all normal.
Computed tomography scan of the abdomen and pelvis (CT A/P) revealed marked dilation of the colon distal to the coloproctostomy, measuring up to 17 cm. The remainder of the colon was air filled and mildly dilated, with colonic wall thickening extending from the hepatic flexure to the anastomosis. The anastomotic sutures were intact. The prostate was markedly enlarged to 8.6 cm.
CT IMAGES
Figure 1: CT A/P showing 8.6 cm prostate.
Figure 2: CT A/P showing marked distal colonic distention.
Colonoscopy revealed a patent anastomosis at 20 cm from the anal verge. A nodular, ulcerated, circumferential, obstructing lesion was noted at 40 cm. Multiple biopsies were taken
COLONOSCOPY IMAGES
Figure 3: Patent anastomosis at 20 cm.
Figure 4: Nodular, obstructing lesion at 40 cm.
Hospital Course
Pathology from the colonoscopic biopsies revealed ulceration with granulation tissue consistent with an inflammatory pseudopolyp.
The patient was thought to have two areas of obstruction: extrinsic compression from the markedly enlarged prostate, and the inflammatory pseudopolyp at 40 cm. Surgery was consulted, and the patient underwent a transverse loop colostomy with sigmoid decompression via rectal tube.
Shortly after surgery, the pathology was addended, noting characteristic viral inclusions and immunohistochemical staining positive for cytomegalovirus (CMV)
PATH IMAGES
Figure 5: Enlarged nuclei and cytoplasms represent the characteristic ground glass type of viral inclusions.
Figure 6: Positive CMV imunohistochemical stain.
Question: What is the diagnosis?
Answer: CMV Pseudotumor
Discussion
CMV is an enveloped, double-stranded Herpes virus. CMV infection refers to viral replication without symptoms, and CMV disease is characterized by infection with symptoms. Primary infection is usually seen in younger patients, and is characterized by a mononucleosis-type syndrome. Secondary infection, with an activation of latent infection by an immunocompromised state, occurs in older adults, and usually manifests with specific organ involvement. Over 60% of adults show evidence of prior infection.
Diagnosis can be supported by serum viral PCR, but must be confirmed by tissue biopsy. The gold standard is tissue culture, but this can take weeks and is not used clinically. Histopathology, showing giant cells with cytomegaly and basophilic inclusion bodies, has a low sensitivity (20%) but is highly specific (100%). Immunohistochemistry has a high sensitivity (approximately 90%) and specificity (100%). Tissue PCR also has a high sensitivity and specificity (91% and 85.4%, respectively).
CMV is disease is usually found in immunocompromised hosts with an activation of latent infection. However, it has also been described in immunocompetent individuals. The most common area of involvement is the gastrointestinal tract, with esophagitis and colitis as the most common pathology. Pulmonary, ocular, CNS, and hematologic involvement can also occur.
CMV colitis in immunocompetent patients manifests most often with fever, diarrhea, and abdominal pain. Given its rarity, the epidemiology is unclear; however, the mean age seems to be in the 6th or 7th decade. The left colon is most commonly involved, but multiple areas of involved in a significant number of patients. Endoscopic features include large, superficial ulcers, nodularity, pseudomembranes, and pseudopolyps. Mortality ranges from 27-32%, with age over 55 years-old being a significant risk factor. Approximately one-third of patients have spontaneous remission, with a significant number of patients requiring antivral therapy, surgical resection, or a combination of both.
Antiviral treatment with intravenous ganciclovir for 2-3 weeks has been successful. More recently, the use of oral valganciclovir has also shown efficacy. IV foscarnet is reserved for patients with ganciclovir resistance or ganciclovir-induced cytopenias. Given the significant mortality from CMV colitis and the risk of surgical complications, most experts recommended treatment in immunocompetent hosts, especially if older aged.
CMV pseudotomors can occur throughout the GI tract, most commonly in the cecum and transverse colon. They can present as friable, stenosing lesions or as large, intraluminal, polypoid masses. There are rare reports in patients with AIDS or organ transplant. Less than five cases have been reported in immunocompetent individuals, all of whom were over age 65. Most of these cases resolved after treatment with ganciclovir, with one resolving with only supportive care and observation.
The role of CMV as a pathogen in colonic inflammation is controversial, as CMV can secondarily colonize inflamed bowel and may also colonize organs without evidence of pathologic involvement. In these cases CMV may be an “innocent bystander.” Before attributing inflammation to CMV, other etiologies must be investigated, including inflammatory bowel disease, ischemia, diverticulosis, and prolapse.
Patient Outcome
The patient had a positive CMV serum PCR (viral load 1927 IU/mL). Treatment with IV ganciclovir was initiated, and he completed a 21day course with transition to oral valganciclovir on discharge. He was asymptomatic at one- and three-month follow-up, and repeat CMV serum PCR was negative after treatment. Given his advanced age and medical comorbidities, no further endoscopy or surgery was considered.
Summary
- Colonic CMV has been reported in immunocompetent patients
- Diagnosis requires endoscopy and biopsy
- Young individuals may have self-limiting disease
- Older individuals are at high risk for complications and usually require treatment with antiviral agents
References
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