Rectal stenosis caused by cytomegalovirus colitis

A 87-year-old man attended our hospital for watery diarrhea since 1 week. Colonoscopy revealed multiple 3 – 6 mm superficial ulcerations in the rectum ([Fig. 1]). The ulcers were shallow and had sharp margins ([Fig. 2]). Cytomegalovirus (CMV) pp65 antigenemia assay (C7-HRP; SRL Inc, Japan) revealed many CMV-positive cells (6/1400 cells). Because CMV viremia was strongly suspected, treatment was initiated with ganciclovir. Immunohistochemistry of biopsy specimens taken from the ulcer craters revealed intranuclear inclusions that were positive for immunostaining with specific anti-CMV antibodies. After 7 days, the diarrhea ceased. At follow-up 2 months later, colonoscopy ([Fig. 3]) and barium enema ([Fig. 4]) both revealed pinpoint stenosis at the rectosigmoid junction, related to the ulcer scars. We took this to mean a cure in endoscopic terms.

Fig. 1 Colonoscopy showing multiple superficial ulcerations in the rectum, 3 – 6 mm in size.

Fig. 2 Colonoscopy with indigo carmine stain revealed shallow ulcerations with sharp margins in the rectum.

Fig. 3 Colonoscopy after 2 months showing pinpoint stenosis as a result of scarring of ulcers at the rectosigmoid junction.

Fig. 4 Barium enema after 2 months showing pinpoint stenosis as a result of scarring of ulcers at rectosigmoid junction.

CMV is an important and ubiquitous herpes virus, and the gastrointestinal tract is one of the common sites of infection [1]. Colonoscopy in our case revealed superficial ulcerative colitis. The pathogenesis of CMV-induced ulcerations is thought to involve ischemic mucosal injury secondary to infection of vascular endothelial cells [2]. In addition, it is well known that rectal stenosis is caused by inflammatory bowel disease such as ulcerative colitis and Crohn’s disease [3] [4]. However, in our case, we thought that the stenosis was a result of the circumferential location of the rectal ulcers. To our knowledge, this is the first reported case of rectal stenosis caused by CMV colitis.

Endoscopy_UCTN_Code_CCL_1AD_2AZ

Reference

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• 4 Gumaste V, Sachar D B, Greenstein A J. Benign and malignant colorectal strictures in ulcerative colitis.  Gut. 1992;  33 938-941