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Keywords
AIDS, CMV colitis, colonic mass, pseudotumor.
Disclaimer
This article will be presented as a clinical vignette poster at the 69th Annual Scientific Meeting of the American College of Gastroenterology on November 1, 2004: “CMV Pseudotumor of the Colon in an AIDS Patient.”
Introduction
Cytomegalovirus (CMV) infection can cause mass lesions of the gastrointestinal tract in patients who are immune-compromised. We describe a rare case of gastrointestinal CMV infection presenting as a colonic pseudotumor in an acquired immunodeficiency syndrome (AIDS) patient.
Methods for Image Capture/Processing
An Olympus CF-Q160L colonscope was used. Images were captured using the Endosoft (Version 5.0) Endoscopic Database software.
Case/Body
A 47-year-old homosexual man with AIDS, CD4 count of 5 per mm3 and viral load > 750,000 copies/mL, presented with several days of lower abdominal pain. He denied having fever, diarrhea, or hematochezia. His past medical history was significant for Pneumocystis carinii pneumonia and a PPD positive skin test that was appropriately treated with isoniazid. The patient was not taking any medication or antiretroviral treatment at the time of his presentation due to noncompliance. On examination, the patient was afebrile and normotensive. His abdomen was tender in the low midline area without peritoneal signs. Initial labs reported WBC 3.6 x 109/L (38% segmented neutrophils, 43% bands), HgB 10.8 g/dL, anion gap 9, and LDH 472 IU/L.
Abdominal CT (Figure 1) showed bowel wall thickening in the ileocecal segment and appendix, with adjacent fat stranding. Stool studies, which included acid-fast bacillus and ova and parasite, and blood cultures which included CMV, were negative. Colonoscopy revealed a 5 cm ulcerated mass in the cecum extending into and through the ileocecal valve (Figure 2). Numerous biopsies were taken which demonstrated cytomegalic cells with cytoplasmic inclusions, consistent with CMV colitis (Figure 3).
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Figure 1 |
Figure 2 |
Figure 3 |
The patient was given oral valganciclovir. Antiretroviral therapy for human immunodeficiency virus (HIV) was not instituted due to concerns for noncompliance. The patient failed to follow-up and presented only several months later after having developed non-Hodgkins lymphoma. Re-examination of the original abdominal CT and previous ileocecal biopsies indicated that the lymphoma on this presentation was new. He died shortly thereafter. Autopsy was declined.
Discussion
CMV is an opportunistic infection that can be seen in AIDS patients with CD4 < 50 per mm3, and in patients on immune-suppression for solid organ transplantation. In these people, CMV disease usually represents re-activation of an infection acquired earlier in life. The most common manifestations are retinitis and gastrointestinal tract involvement, particularly CMV colitis. Until the advent of HIV antiretroviral therapy, CMV gastrointestinal disease was seen in up to 30% of the AIDS population (1). Since the late 1980s and the introduction of highly-active antiretroviral therapy (HAART), CMV complications of the gastrointestinal tract have become less common in the HIV population. In the transplant population, the appropriate use of CMV antiviral prophylaxis has also decreased its incidence.
There have been only a few reports describing CMV colitis presenting as a colonic pseudotumor. Mass lesions of the colon in AIDS patients typically represent a neoplasm, particularly Kaposi’s sarcoma (60%) or lymphoma (35%) (1). Infectious mass lesions are less common, usually representing mycobacterium tuberculosis or histoplasmosis infection (2). Only six cases of CMV pseudotumor of the colon have ever been reported: five had underlying AIDS and one was a renal transplant patient on immune-suppression (1-4). An equal number of case reports exist describing CMV mass lesions in the esophagus and stomach (3,5-6), all of which were immune-suppressed. Curiously, most of the patients with CMV pseudotumors of the colon did not have diarrhea or fever at the time of their presentation. Many had non-diagnostic colon biopsies and were only diagnosed after surgical resection for presumed malignancy. The affected tissue consists of inflammatory cells with fibrosis, granulation formation, and CMV cytoplasmic inclusions. In a couple of cases, however, the diagnosis was able to be made on endoscopic workup; these unique cases were treated with intravenous ganciclovir, and the mass lesions eventually diminished on follow-up examination (1-3).
In conclusion, a CMV pseudotumor is rare but should be considered in the differential of a colonic mass lesion in an AIDS patient. This is a lesion that can potentially be treated by antiviral therapy when a diagnosis is made on endoscopic workup.
References
1.Goyal R and Goyal S. Cytomegalovirus infection in AIDS presenting as a rectal mass. Am J Gastroenterol 2000;95(1):327-8.
2. Napierkowski J, Sachar D, Cumings M, Wong R. Cytomegalovirus infection presenting as a polypoid colonic mass. Am J Gastroenterol 2002; 97(9):S160-1.
3. Rich J, Crawford J, Kazanjian S, Kazanjian P. Discrete gastrointestinal mass lesions caused by cytomegalovirus in patients with AIDS: report of three cases and review. Clin Infect Dis 1992;15:609-14.
4. Wisser j, Zingman B, Wasik M, Duva-Frissora A, Beazley R, McAneny D. Cytomegalovirus pseudotumor presenting as bowel obstruction in a patient with acquired immunodeficiency syndrome. Am J Gastroenterol 1992; 87(6):771-4.
5. Elta G, Trunage R, Eckhauser F, Agha F, Ross S. A submucosal antral mass caused by cytomegalovirus infection in a patient with acquired immunodeficiency syndrome. Am J Gastroenterol 1986;81(8):714-7.
6. Garcia F, Garau J, Sierra M, Marco V. Cytomegalovirus mononucleosis-associated antral gastritis simulating malignancy. Arch Intern Med 1987;147:787-8.
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