A65 SEVERE CYTOMEGALOVIRUS COLITIS MASQUERADING AS RECURRENT ISCHEMIC COLITIS IN PATIENT WITH END-STAGE RENAL DISEASE

Severe Cytomegalovirus (CMV) colitis is a rare condition, most commonly seen in immunocompromised patients. We describe a case of CMV colitis masquerading as recurrent ischemic colitis in a patient with end-stage renal disease (ESRD). Describe a case of severe CMV colitis presenting as recurrent ischemic colitis. Case report Case: A 44 year-old man with atherosclerotic risk factors including hypertension, diabetes mellitus, ESRD on hemodialysis and morbid obesity presented twice to our emergency department (ED) within 14 days with hematochezia, acute abdominal pain, fever, leukocytosis, and an elevated serum lactate. Computed tomography scan of the abdomen (CT-Abdo) demonstrated changes consistent with isolated right colon ischemia (IRCI). Colonoscopy showed circumferential ulcerated mucosa with greyish discoloration and sloughing of the mucosa starting at the hepatic flexure and extending proximally, potentially due to ischemic colitis (figure 1). There was a sharp demarcation between the normal and ulcerated mucosa, and, in view of possible ischemia, the endoscope was not introduced further. A colonic biopsy at the edge of demarcation was taken and showed non-specific small ulcerations. The patient improved with conservative management including intravenous fluids and antibiotics. He was discharged home with resolution of symptoms. He unfortunately returned to our ED two weeks later with a third episode of hematochezia, abdominal pain and hemorrhagic shock. Repeat CT-Abdo showed persistent IRCI with new pneumatosis intestinalis. As he failed to improve with vasopressors, blood transfusions, and antibiotic therapy, an urgent right hemicolectomy was performed. On pathology, multiple CMV organisms were identified with ulcerations and perforation, consistent with severe CMV colitis. CMV PCR was only minimally elevated (80copies/mL). IV ganciclovir was initiated. On follow-up visit, the patient demonstrated sustained clinical improvement, and no recurrence of symptoms. IRCI is an uncommon form of ischemic colitis, but occurs more frequently in patients with significant atherosclerosis and hemodialysis. Despite initial improvement, the patient’s symptomatic recurrence was initially attributed to his severe vasculopathy, coupled with ongoing hemodialysis causing fluid shifts. In a review of the literature of 14 cases with ESRD and CMV GI disease, 72% presented with lower GI bleeding, colonoscopy showed ulceration or polypoid lesions, and was associated with a 35% mortality. CMV colitis should be suspected in atypical cases of ischemic colitis, and early diagnosis may avoid significant morbidity. Sharp area of demarcation with circumferentially ulcerated and sloughing mucosa None

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