CMV Colitis in an HIV Positive Patient with CD 4 greater than 200

Case Report A 28-year-old male known to have HIV was admitted with a one-week history of worsening fatigue, nausea, vomiting, 2 kg weight loss, and constipation. Blood pressure was 110/70 mmHg. Heart rate was 105 bpm and body temperature was 37.2 C. On physical examination, the patient looked dehydrated. His abdomen was tender to palpation without guarding. Bowel sounds were normal. Initial lab work showed sodium at 130 mEq/l, albumin at 2.2 g/dl, and white blood count at 15.9 K/cmm with normal differentials. Blood cultures were negative. On admission, his CD4 count was 223 cells/ml and viral load was 5350 copies per ml. Three months prior, his CD4 count was 666 cells/ml with 1960 HIV RNA copies per ml. A kidney, ureter, and bladder (KUB) xray study showed small bowel obstruction. A nasogastric tube was inserted. Computed tomography (CT) of the abdomen showed multiple air and fluid filled loops of small bowel with marked edema of distal small bowel. Colonoscopy revealed congested and erythematous mucosa with skip areas within the proximal, middle, and distal transverse colon and congestive mucosa within the terminal ileum with prominent Peyer’s patches. Serum cytomegalovirus (CMV) PCR was 3250 IU/mL. Histological findings in colonic biopsies revealed active inflammation with ulceration (Figure 1) and characteristic large cells (Figure 2). CMV infection could be confirmed immunohistochemically (Figure 3). The patient was started on IV ganciclovir. Highly active anti-retroviral therapy (HAART) was initiated with efavirenz, emtricitabine, and tenofovir. The patient improved. He was discharged on ganciclovir 450 PO BID and HAART. Three weeks later, the patient was seen at primary care physician’s office with clinical improvement and repeat serum CMV PCR was negative.


Case Report
A 28-year-old male known to have HIV was admitted with a one-week history of worsening fatigue, nausea, vomiting, 2 kg weight loss, and constipation.Blood pressure was 110/70 mmHg.Heart rate was 105 bpm and body temperature was 37.2 C.
On physical examination, the patient looked dehydrated.His abdomen was tender to palpation without guarding.Bowel sounds were normal.Initial lab work showed sodium at 130 mEq/l, albumin at 2.2 g/dl, and white blood count at 15.9 K/cmm with normal differentials.Blood cultures were negative.
On admission, his CD4 count was 223 cells/ml and viral load was 5350 copies per ml.Three months prior, his CD4 count was 666 cells/ml with 1960 HIV RNA copies per ml.A kidney, ureter, and bladder (KUB) xray study showed small bowel obstruction.A nasogastric tube was inserted.Computed tomography (CT) of the abdomen showed multiple air and fluid filled loops of small bowel with marked edema of distal small bowel.Colonoscopy revealed congested and erythematous mucosa with skip areas within the proximal, middle, and distal transverse colon and congestive mucosa within the terminal ileum with prominent Peyer's patches.Serum cytomegalovirus (CMV) PCR was 3250 IU/mL.
Histological findings in colonic biopsies revealed active inflammation with ulceration (Figure 1) and characteristic large cells (Figure 2).CMV infection could be confirmed immunohistochemically (Figure 3).The patient was started on IV ganciclovir.Highly active anti-retroviral therapy (HAART) was initiated with efavirenz, emtricitabine, and tenofovir.
The patient improved.He was discharged on ganciclovir 450 PO BID and HAART.Three weeks later, the patient was seen at primary care physician's office with clinical improvement and repeat serum CMV PCR was negative.

Discussion
CMV colitis can occur in up to 7.3% of persons with AIDS. 5CMV colitis occurs late in the course of HIV infection. 6The risk of opportunistic infections in patients with HIV has been known to be dependent on the degree of immunodeficiency as measured by CD4 T cells.Ulcers caused in the gastrointestinal tract by CMV infection are observed usually when the number of CD4 decreases to less than 50 cells/μL to 100 cells/μL.For example, Wilcox et al. 7 reported CMV colitis in 56 HIV patients, most with severe immunodeficiency and a median CD4 count of 15 cells/μL.
Few cases of CMV colitis in HIV positive patients with CD4 count more than 200 cells/ μL have been reported.Yotsumoto and colleagues 2 reported cytomegalovirus esophagitis and colitis, esophageal candidiasis and colon amebiasis in an HIV patient with CD4 count more than 200 cells/ μL.Wolf and colleagues 3 reported a case of severe CMV colitis in an HIV positive woman with relatively preserved CD4 count.Smith and colleagues 4 reported a case of a patient with CMV colitis and a CD4 count of 800.
Explanations of acquiring CMV colitis with relatively higher CD4 counts include poor nutritional status or alcohol consumption. 8Our patient denied alcohol abuse.Surawicz et al. 9 reported CMV colitis in immunocompetent individuals as a consequence of receptive anal intercourse.Our patient was a man who had sex with men, so there was possibility of an anal mucosa tear.Another possibility is dysfunction of T cells secondary to HIV virus, although it is difficult to prove. 2

Conclusion
Although gastrointestinal manifestations of CMV in patients with advanced HIV disease are well described, this case highlighted that CMV colitis also can occur in patients with CD4 counts greater than 200.CMV colitis should be included in the differential diagnosis of any HIV-positive patient presenting with lower gastrointestinal symptoms, regardless of their CD4 counts.

Figure 1 .
Figure 1.H&E stained section of mucosa with ulceration and inflammation.

Figure 2 .
Figure 2. H&E stained section showing 3 large cells with large nucleus, eosinophilic nucleolus, and stippled appearance of cytoplasm admixed with mostly small lymphocytes and a few eosinophils.