Lee Chun-Yuan, Chen Yen-Hsu, Lu Po-Liang
Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
BMC Infect Dis. 2017 Feb 1;17(1):113. doi: 10.1186/s12879-017-2218-y.
Reactivated cytomegalovirus (CMV) infection has been known to cause significant morbidity and mortality in immunocompromised patients. However, CMV disease rarely develops in immunocompetent patients, and reported cases often present with a mild, self-limiting course, without severe life-threatening sequelae. While the colon is the most common gastrointestinal site affected by CMV disease in immunocompetent patients, rectal involvement is rarely reported. CMV proctitis can present in two distinct forms, primary and reactivated. However, reactivated CMV proctitis is rarely reported as a causative etiology of nosocomial diarrhea, except in transplant patients. Herein we present a case of reactivated CMV proctitis in an immunocompetent patient, presenting as nosocomial diarrhea. Previously reported cases of reactivated CMV proctitis in immunocompetent patients are also reviewed.
A 79-year-old female was admitted because of metabolic encephalopathy caused by dehydration and hypernatremia. The patient's consciousness level returned rapidly after fluid supplementation. However, she subsequently presented with abdominal pain and diarrhea on day 8 of admission. Abdominal contrast-enhanced computed tomography on day 10 of admission demonstrated inflammation around the rectum, suggesting proctitis. Colonoscopy on day 16 of admission showed a giant ulcer at the rectum. Pathology of rectal biopsy confirmed CMV infection. The patient recovered without sequelae after 38 days of valganciclovir treatment. Follow-up colonoscopy revealed a healed ulcer over the rectum. Ten cases in the literature, plus our case, with reactivated CMV proctitis in immunocompetent patients were reviewed. We found that most patients were elderly (mean, 72 years) with a high prevalence of diabetes mellitus (54.5%). Cardinal manifestations are often non-specific (diarrhea, hematochezia, tenesmus), and eight (72.7%) developed CMV proctitis following a preceding acute, life-threatening disease, rather than as an initial presentation on admission. These manifestations frequently develop during hospitalization, and are thus often regarded as nosocomial diarrhea.
Clinicians should be aware of the possibility of nosocomial onset of reactivated CMV proctitis in patients hospitalized due to a preceding critical illness, although the benefits of antiviral therapy remain unclear.
已知重新激活的巨细胞病毒（CMV）感染会在免疫功能低下的患者中导致显著的发病率和死亡率。然而，CMV疾病在免疫功能正常的患者中很少发生，且报告的病例通常表现为轻度、自限性病程，无严重危及生命的后遗症。虽然结肠是免疫功能正常的患者中受CMV疾病影响最常见的胃肠道部位，但直肠受累情况很少被报道。CMV直肠炎可表现为两种不同形式，即原发性和重新激活型。然而，除了移植患者外，重新激活的CMV直肠炎作为医院获得性腹泻的病因很少被报道。在此，我们报告一例免疫功能正常的患者发生重新激活的CMV直肠炎，表现为医院获得性腹泻。同时，我们也回顾了先前报道的免疫功能正常的患者中重新激活的CMV直肠炎病例。
一名79岁女性因脱水和高钠血症引起的代谢性脑病入院。补液后患者意识水平迅速恢复。然而，入院第8天她随后出现腹痛和腹泻。入院第10天的腹部增强计算机断层扫描显示直肠周围有炎症，提示直肠炎。入院第16天的结肠镜检查显示直肠有一个巨大溃疡。直肠活检病理证实为CMV感染。经缬更昔洛韦治疗38天后，患者康复且无后遗症。随访结肠镜检查显示直肠溃疡已愈合。我们回顾了文献中10例加上我们的病例，这些都是免疫功能正常的患者发生重新激活的CMV直肠炎的病例。我们发现大多数患者为老年人（平均72岁），糖尿病患病率较高（54.5%）。主要表现通常是非特异性的（腹泻、便血、里急后重），8例（72.7%）在先前患有急性、危及生命的疾病后发生CMV直肠炎，而非入院时的初始表现。这些表现常在住院期间出现，因此常被视为医院获得性腹泻。
临床医生应意识到因先前患有危重病而住院的患者可能发生医院获得性重新激活的CMV直肠炎，尽管抗病毒治疗的益处尚不清楚。
