Woman With CMV Colitis

A 41-year-old woman with a 4-yearhistory of polymyositis with lupus featureshas had constant rectal pain for4 months. She has not noticed any factorsthat either aggravate or relievethe pain. The patient complains of intermittentconstipation (but no dischargeor rectal bleeding), generalizedweakness and malaise for the past 2months, a low-grade fever for the pastmonth, and a 4.1-kg (9-lb) weight lossover the past 6 weeks. She denies nightsweats or chills, anorexia, vision problems,drug allergies, and tobacco oralcohol use.She has a family history of hypertensionand diabetes mellitus. For thepast 4 years, she has been receiving immunosuppressivetherapy: currently,20 mg of prednisone and 150 mg of azathioprineper day. She also takes cimetidineand a multivitamin supplement.The patient is well oriented totime, place, and person. Heart rate is102 beats per minute; temperature,37.7C (99.8F); blood pressure,110/66 mm Hg; and respiration rate,18 breaths per minute. Rectal examinationreveals moderate tendernesswith heme-negative stool. The remainderof the examination is normal.White blood cell count is 2600/?L(normal, 4000 to 11,000/?L), with87% segmented forms, 7.9% lymphocytes,4.9% monocytes, and 0.1% basophils.Hemoglobin level is 9 g/dL;hematocrit, 33.9%; and platelet count,184,000/?L (normal, 150,000 to450,000/?L). Serum electrolyte levelsand renal and liver function test resultsare normal. Results of a tuberculintest and a chest radiograph also arenormal.Flexible sigmoidoscopy shows erythemawith ulcers in the sigmoid colonand rectal area and internal hemorrhoids(Figure 1). A biopsy specimen ofthe sigmoid colon reveals multifocalviral inclusions in epithelial as well asendothelial cells consistent with cytomegalovirus(CMV) colitis (Figure 2).A 5-week course of intravenous gancicloviris started. Two weeks afterdischarge, all symptoms have resolved.CMV INFECTION:AN OVERVIEWAlthough more than 40% of thegeneral population is infected withCMV, symptoms are typically seen only in children. The infection is generallyasymptomatic in immunocompetentadults.