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  Table of Contents    
CASE REPORT  
Year : 2015  |  Volume : 58  |  Issue : 1  |  Page : 80-82
Cytomegalovirus colitis masquerading as rectal malignancy in an immunocompetent patient


1 Department of Pathology, Bahrain Specialist Hospital, Juffair, Manama, Bahrain
2 Department of Medical Gastroenterology, Bahrain Specialist Hospital, Juffair, Manama, Bahrain

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Date of Web Publication11-Feb-2015
 

   Abstract 

Gastrointestinal tract (GIT) involvement by cytomegalovirus (CMV) infection is well-recognized in immunosuppressed patients but is uncommon in immunocompetent hosts. The colon and esophagus are the most frequently affected sites with punched out ulcers being the characteristic mucosal lesion. CMV-induced pseudotumor is an exceptionally rare presentation, especially in immunocompetent hosts. A 76-year-old immunocompetent female presented with abdominal pain and constipation. Colonoscopy revealed an ulcerated polypoidal tumor-like mass in the anorectal region. Biopsy of the lesion showed large basophilic intranuclear inclusions which were positive for CMV on immunohistochemical staining. The patient responded to 2 weeks of antiviral therapy with complete resolution of the mass. Although rare, pseudotumors associated with CMV infection should be considered in the differential diagnosis of tumorous lesions of the GIT.

Keywords: Cytomegalovirus, gastrointestinal tract, immunocompetent, pseudotumor, rectum

How to cite this article:
Jacob S, Zayyani NR. Cytomegalovirus colitis masquerading as rectal malignancy in an immunocompetent patient. Indian J Pathol Microbiol 2015;58:80-2

How to cite this URL:
Jacob S, Zayyani NR. Cytomegalovirus colitis masquerading as rectal malignancy in an immunocompetent patient. Indian J Pathol Microbiol [serial online] 2015 [cited 2020 Apr 9];58:80-2. Available from: http://www.ijpmonline.org/text.asp?2015/58/1/80/151195



   Introduction Top


Clinically significant cytomegalovirus (CMV) disease is well-recognized in patients with AIDS and those on immunosuppressive agents. [1],[2],[3],[4] On the other hand, the disease is asymptomatic or runs a benign course manifesting mild mononucleosis-like syndrome in immunocompetent individuals. [2],[5] However, the recent years have seen a rising number of cases of severe CMV infection in immunocompetent persons, especially in elderly with other co-morbidities. [2],[5],[6]

Although any part of the gastrointestinal tract (GIT), from the mouth to the anus may be affected, the most frequent sites are the colon and the esophagus. [1],[2],[3],[4],[7] The characteristic mucosal lesion of CMV infection is featured by punched out ulcerations. CMV-induced pseudotumor of the GIT is an unusual occurrence, mainly described in the background of immunosuppression. [4],[8],[9] Even more exceptional are similar mass lesions occurring in immunocompetent individuals. [5],[9] This report documents a rare case of CMV-associated rectal pseudotumor in an immunocompetent elderly female.


   Case Report Top


A 76-year-old lady presented with a 1 week history of severe constipation, anal and abdominal pain and bloating. She gave a history of chronic constipation for which she took laxatives on and off and occasionally resorted to digital evacuation. She appeared frail and pale. Her hemoglobin was 10 g/dl and stools were positive for occult blood. An upper gastrointestinal endoscopy was unremarkable. Colonoscopy revealed a 3 cm × 2 cm ulcerated sessile polypoidal mass in the ano-rectal region located 1 cm from the anorectal junction, seen on retroflexed view of the rectum [Figure 1]. Rectal malignancy was considered, and multiple mucosal biopsies taken. The serum CEA level was 0.4 ng/ml.
Figure 1: An ulcerated sessile polypoidal mass in the ano-rectal region


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Histopathologic examination revealed numerous polypoid pieces of exuberant granulation tissue and partly ulcerated ano-rectal mucosal fragments with intense inflammation. The granulation tissue exhibited the edema, numerous proliferating capillaries with plump endothelial cells, young fibroblasts, neutrophils, histiocytes including few multinucleated giant cells, lymphocytes, and occasional plasma cells. A careful scrutiny disclosed occasional large basophilic intranuclear inclusions within fibroblasts, compatible with CMV inclusions [Figure 2] and [Figure 3]. Immunohistochemistry (IHC) staining with CMV antibodies on paraffin sections done in a referral laboratory confirmed the diagnosis. There was no evidence of neoplastic pathology.
Figure 2: Exuberant granulation tissue with young capillaries. A rare cytomegalovirus inclusion with cytomegaly noted (arrow). H and E, ×200


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Figure 3: Highly magnified view of cytomegalovirus intranuclear inclusion within stromal fibroblast (arrow). H and E, ×1000


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Serum CMV IgG antibody levels were >250 U/ml while CMV IgM antibodies were not detected. The patient was given ganciclovir therapy for 2 weeks. A repeat colonoscopy done after 6 weeks showed complete regression of the mass.


   Discussion Top


The GIT is a frequent site of CMV infection. The colon, especially the rectosigmoid and cecum, is the most favored site followed by the esophagus and occasionally the stomach and small intestine. [1],[2],[3],[4] The clinical manifestations are diverse and dependent on the affected site and intensity of infection. [2],[4],[7]

The prototypical lesions induced by CMV in the GIT are punched out ulcerations, erosions, perforations, hemorrhages, or stenosis. Infrequently it manifests as toxic megacolon, pseudomembrane formation, and ischemic colitis. [5],[7] Even more unusual and less well recognized forms of CMV infection are tumefactive inflammatory masses. These have mostly been reported in immunodeficient patients. [4],[8],[9],[10] Very few such cases have been described in apparently immunocompetent hosts. [3],[5],[9]

Although there are various diagnostic tools for CMV colitis such as serological analysis, viral cultures, and antigen studies using polymerase chain reaction, the tissue biopsy remains the gold standard test. [7] The histopathological hallmark of CMV infection is the eye-catching "owl's-eye" like basophilic intranuclear viral inclusions within endothelial cells, mucosal epithelium, or connective stromal cells. [1],[7] IHC staining employing antibodies to CMV antigens is helpful in cases where the number of viral inclusions are scarce. [7]

Cytomegalovirus infection in immunocompetent patients may be the result of primary infection or a secondary reactivation. [1],[6] The frequency of CMV reactivation increases linearly with age because of the decline in immunity. [1],[9] The other risk factors for CMV disease include co-morbidities such as diabetes mellitus, renal failure, severe sepsis, malnutrition, major trauma, widespread burns, and postsurgical states. [1],[3],[6],[9] The virus itself may exert a direct immunosuppressive action. Local trauma sustained during anal intercourse may have a causative role with mucosal damage providing a repository for infection. [7] In our patient, old age with the associated fall in immunity may have been a major risk factor. The traumatized rectal mucosa as a result of self-digitalization for her chronic constipation may have been the portal of entry of infection.

Spontaneous remission occurs in some patients with CMV disease but immunocompromised patients and patients older than 55 years of age with immune-modulating co-morbidities require antiviral treatment. [1],[5]


   Conclusion Top


Cytomegalovirus infection of the GIT may not be suspected in seemingly immunocompetent individuals. This is even more so when it presents as an inflammatory tumor-like mass, an under-recognized morphologic form. In such cases, a diligent search, visually sifting through the granulation tissue for the footprints of the virus, viz., the large intra-nuclear basophilic inclusions, is warranted. Highlighting the affected cells by IHC staining employing CMV antibodies is helpful in those instances where the inclusions are infrequent or masked by the accompanying heavy inflammatory infiltrate.

 
   References Top

1.
Rankin A, Cuthill K, Subesinghe M, Goldsmith D. Life-threatening rectal bleeding due to cytomegalovirus colitis in a haemodialysis patient. Clin Kidney J 2009;2:239-41.  Back to cited text no. 1
    
2.
Rafailidis PI, Mourtzoukou EG, Varbobitis IC, Falagas ME. Severe cytomegalovirus infection in apparently immunocompetent patients: A systematic review. Virol J 2008;5:47.  Back to cited text no. 2
    
3.
Kanno M, Chandrasekar PH, Bentley G, Vander Heide RS, Alangaden GJ. Disseminated cytomegalovirus disease in hosts without acquired immunodeficiency syndrome and without an organ transplant. Clin Infect Dis 2001;32:313-6.  Back to cited text no. 3
    
4.
Kelesidis T, Tozzi S, Mitty R, Worthington M, Fleisher J. Cytomegalovirus pseudotumor of the duodenum in a patient with AIDS: An unrecognized and potentially treatable clinical entity. Int J Infect Dis 2010;14:e274-82.  Back to cited text no. 4
    
5.
Kawasaki S, Osawa S, Sugimoto K, Uotani T, Nishino M, Yamada T, et al. Cecal vanishing tumor associated with cytomegalovirus infection in an immunocompetent elderly adult. World J Gastrointest Oncol 2010 15;2:417-20.  Back to cited text no. 5
    
6.
Szary NM, Kuwajima VK, Jiang PP, Puli SR, Bragg JD, Bechtold ML. Cytomegalovirus colitis in an immunocompetent host: A case report and review of the literature. Internet J Gastroenterol 2007;7:1.  Back to cited text no. 6
    
7.
Chetty R, Roskell DE. Cytomegalovirus infection in the gastrointestinal tract. J Clin Pathol 1994;47:968-72.  Back to cited text no. 7
    
8.
Chow PK, Ho JM, Ling AE, Goh HS. CMV colitis masquerading as colon cancer - an unusual presentation of acquired immunodeficiency syndrome. Singapore Med J 1997;38:32-4.  Back to cited text no. 8
    
9.
Maiorana A, Torricelli P, Giusti F, Bellini N. Pseudoneoplastic appearance of cytomegalovirus-associated colitis in nonimmunocompromised patients: Report of 2 cases. Clin Infect Dis 2003;37:e68-71.  Back to cited text no. 9
    
10.
Rich JD, Crawford JM, Kazanjian SN, Kazanjian PH. Discrete gastrointestinal mass lesions caused by cytomegalovirus in patients with AIDS: Report of three cases and review. Clin Infect Dis 1992;15:609-14.  Back to cited text no. 10
    

Top
Correspondence Address:
Dr. Sunitha Jacob
Department of Pathology, Bahrain Specialist Hospital, Juffair, Manama
Bahrain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.151195

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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