He was admitted with a week history of worsening bloody diarrhoea and high fever. He had been diagnosed with ulcerative colitis 10 years earlier. His medication on admission included prednisolone 20 mg per day, mesalazine 400 mg three times a day, and azathioprine 50 mg twice a day.
On examination he is pyrexial with a temperature of 38.5°C and is tender in the left iliac fossa.
Hb 13.5 g/dl Na 140 mmol/l
WBC 3.2 x 10 9 K 4.0 mmol/l
Plat 300 x 109 Urea 7.5 mmol/l
ESR 18 mm/h Creat 52 µmol/l
CRP 120 Glucose 5.2 mmol/l
Bili 15 µmol/l
ALP 990 iu/l
AST 375 iu/l
Albumin 34 g/l
The leucopenia progressed 48 hours after admission (white cell count 2.6 x 109/l, neutrophils 2.0 x 109/l). Blood, stool, and urine cultures are all negative. In view of the abnormal liver function tests and history of ulcerative colitis, an MRCP is performed to investigate the possibility of primary sclerosing cholangitis, but this is normal.
The patient is started on empirical intravenous cefuroxime and metronidazole 72 hours after admission. However, the swinging pyrexia does not respond to the antibiotics.
A colonoscopy is carried out (see video file) and biopsy specimens are taken (photograph).
What is the diagnosis?
a) ulcerative colitis
b) Crohn’s disease
c) CMV colitis
d) Ischaemic colitis
e) HIV associated colitis
A diagnosis of cytomegalovirus colitis induced immunosuppression was made on the basis of the classical appearance of ‘‘owl’s eye’’ inclusion bodies. The patient was started on IV ganciclovir (5 mg/kg) on day 16 of the admission and became apyrexial 48 hours later.
Patients with inflammatory bowel disease (particularly ulcerative colitis) are predisposed to developing an acute exacerbation secondary to cytomegalovirus disease. In most cases patients are receiving some immune modulatory therapy before the onset of symptoms.
As in this case, CMV can give rise to a self limiting hepatitis. Mortality rates for patients with cytomegalovirus enterocolitis have been quoted as high as 70%.