Refractory ulcerative colitis complicated by a cytomegaloviral infection requiring surgery: report of a case

Cytomegalovirus (CMV) infection has been reported to be a cause of refractory ulcerative colitis (UC). We herein report a case of refractory ulcerative colitis complicated by CMV infection requiring surgery. A 22-year-old man was admitted to our hospital with lower abdominal pain and bloody diarrhea. Under a diagnosis of acute UC, he was treated with prednisone 60 mg/day and sulfasalazine. Since his symptoms appeared to improve, the prednisone dosage was gradually reduced to 20 mg/day. After 5 months, he had an unexpected flare-up with fever and fresh anal bleeding. Colonoscopy demonstrated a punched out ulcer in the sigmoid colon. Biopsies by colonoscopy revealed cytomegalic inclusion bodies. Serologic and immunologic studies also suggested a recent CMV infection. Under a diagnosis of intractable UC complicated by a CMV infection, ganciclovir therapy was carried out, and the steroid therapy was tapered. Although the serum antigenemia became negative after the antiviral therapy, follow-up colonoscopy confirmed the severe stenosis after the punched-out ulcer healed completely. Since his symptoms did not improve, it was necessary to perform an elective proctocolectomy despite antiviral therapy. He was discharged with an uneventful postoperative course. It is important to recognize CMV colitis as a complication of inflammatory bowel disease, particularly in severe steroid-resistant colitis. Furthermore, in cases which fail to respond to antiviral treatment, the patient may ultimately require surgery.