Buckshaw, Ricky, DO

Malik, Anam, MD

Nellis, Eric, MD

Shah, Hiral N, MD

Vaze, Reema M, MD

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Medicine A Case of CMV Colitis Seen in DRESS Anam Malik MD Lehigh Valley Health Network, Anam.Malik@lvhn.org Reema M. Vaze MD Lehigh Valley Health Network, Reema.Vaze@lvhn.org Ricky Buckshaw DO Lehigh Valley Health Network, Ricky.Buckshaw@lvhn.org Eric Nellis MD Lehigh Valley Health Network, eric.nellis@lvhn.org Hiral N. Shah MD Lehigh Valley Health Network, hiral_n.shah@lvhn.org Follow this and additional works at: https://scholarlyworks.lvhn.org/medicine  Part of the Gastroenterology Commons, and the Internal Medicine Commons Published In/Presented At Malik, A. Vaze, R. Buckshaw, R. Nellis, E. Shah, H. (2019, October 25). A Case of CMV Colitis Seen in DRESS. Poster Presented at: American College of Gastroenterology, San Antonio, Texas. This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. © 2019 Lehigh Valley Health NetworkLVHN.orgA Case of CMV Colitis Seen in DRESSAnam Malik, MD,1 Reema Vaze, MD,2 Ricky Buckshaw, DO,2 Eric Nellis, MD,1 Hiral Shah, MD11Department of Gastroenterology, 2Department of Internal Medicine, Lehigh Valley Health Network, Allentown, Pa.Introduction•  Cytomegalovirus ( CMV) is a member of the family of herpes virus, which persists for life after a primary infection. •  It is known to cause colitis in both immunocompromised and immunocompetent hosts. •  CMV enters a latency phase after initial infection. Reactivation can occur anywhere along the gastrointestinal tract. The colonic mucosa is the most common site of reactivation. •  Clinical, endoscopic, and histological appearance of CMV colitis can mimic inflammatory bowel disease. It is important to recognize  the risks of long term  medical treatment with  immunomodulatory drugs  such as leflunomide or corticosteroids, including local reactivation of a latent virus.Case DescriptionA 59-year-old female with rheumatoid arthritis on chronic steroids and recently prescribed leflunomide presented with a diffuse rash, stomatitis, eosinophilic dominant leukocytosis, and severe diarrhea. A skin biopsy confirmed the diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS). The patient’s diarrhea worsened despite negative comprehensive stool panel, clostridium difficile toxin and stool ova/parasites. A CT abdomen revealed diffuse colitis, and as a result the patient underwent flexible sigmoidoscopy showing circumferential colitis with ulcerations (Figure 1). Biopsies taken from the distal colon confirmed Cytomegalovirus (CMV) by viral inclusion bodies seen on hematoxylin-eosin staining (Figure 2). The patient was initiated on IV ganciclovir, however expired after developing septic shock.Discussion•  Gastrointestinal (GI) disease caused by CMV is diagnosed on the presence of clinical symptoms, viral inclusion bodies on biopsy, and endoscopically visualized ulcers. •  The most common sites of CMV related GI involvement is the esophagus and colon. •  Biopsy with immunohistochemical testing using monoclonal antibodies against CMV is considered the gold standard (Figure 3). Owl’s eye inclusion bodies on staining are highly specific for infection with CMV. •  The gastrointestinal tract is thought to contain latent CMV after a primary infection.•  This case highlights the importance of recognizing the risks of long term medical treatment with immunomodulatory drugs such as leflunomide or corticosteroids, including local reactivation of a latent virus as in our patient.Figure 1: Flexible sigmoidoscopy  reveals extensive ulcerations in the descending colon.Figure 2: Histologic study of a biopsy specimen shows  viral inclusions characteristic of cytomegalovirus (hematoxylin-eosin,  × 600).Figure 3: Immunohistochemical staining of the biopsy specimen

A Case of CMV Colitis Seen in DRESS

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