DEPARTMENT OF PATHOLOGY
The Johns Hopkins Medical Institutions
 

Vol. 18, No. 16
THE JOHNS HOPKINS MICROBIOLOGY NEWSLETTER
Monday, May 3, 1999
 

  1. Provided by Leslie Edwards Reger, Division of Outbreak Investigation, Maryland Department of Health and Mental Hygiene.

    2. Outbreaks during MMWR week 15 (4/11-4/17)
    4 outbreaks reported: 1 gastroenteritis outbreak in a nursing home, 3 foodborne gastroenteritis outbreaks associated with food-service facilities

    Outbreaks for MMWR week 16 (4/18 - 4/24/99)
    3 outbreaks reported: 1 gastroenteritis outbreak at a nursing home, 1 foodborne gastroenteritis outbreak in a food-service facility, 1 outbreak of respiratory and GI symptoms among visitors at a resort center.

    Outbreaks during MMWR week 17 (4/25-5/1):
    4 outbreaks reported: 1 outbreak of scabies reported from a health-care facility, 3 outbreaks of foodborne gastroenteritis caused by Salmonella (salmonellosis): 1 occurred at a wedding reception, 1 was at a church dinner, and the third had two possible sources.
     

  2. The Johns Hopkins Hospital. Information provided by Joseph D Kronz, M.D., Department of Pathology.
Clinical Presentation: This is a 43-year-old female with end-stage HIV (CD4 count of 3 and an RNA HIV viral load of 600,000 in 12/98) and renal failure who was readmitted to The Johns Hopkins Hospital after completing two weeks of vancomycin for an Enterococcus faecalis and Staphylococcus epidermidis line infection diagnosed at an outside hospital. At the completion of the antibiotics she was afebrile for some 48-72 hours but began to have fevers to 101 degrees. She has been in and out of hospitals for the last four months with fevers and documented line infection. She also complains of persistent intermittent diarrhea. She has had an extensive investigation including numerous stool studies, MAI and bacterial blood cultures, serum Cryptococcus and Histoplasma antigen studies all of which have been negative. She has had several echocardiograms which have failed to demonstrate any vegetation suggestive of endocarditis. She has had at least one eye exam which did not show evidence of CMV. She is currently on no antiretroviral therapy. She takes Bactrim after each dialysis and azithromycin 1200 mg weekly.

On physical examination at the time of admission, her temperature was 37.7, she was breathing 24 breaths per minute, she was tachycardic at 100 and her blood pressure was 105/75. Funduscopic examination was normal. Her abdomen is soft. Laboratory values on admission showed a sodium of 133 with potassium 3.9, creatinine is 7.2 with a BUN of 23. White count was 2.4 with a normal differential. She had a normal chest x-ray.

During the admission she had no more fevers but continued to have intermittent diarrhea. Her dialysis catheter was not removed. She underwent flexible sigmoidoscopy which revealed the mucosa of the rectosigmoid region to be focally erythematous and pigmented with circular lesions. Multiple biopsies were taken. There was no evidence of mass, polyps or ulceration. The biopsies showed viral cytopathic effects and a immunohistochemical stain was positive for CMV (Figure1).

CMV colitis

Background: Cytomegalovirus belongs to the Herpesvirus family and is a double stranded DNA virus. Like other Herpes viruses CMV has icosahedral symmetry, replicates in the nucleus and can cause lytic or a latent infection. Viral replication within the cell cause large viral inclusions within the nucleus and occasionally smaller inclusions in the cytoplasm. Once infections occurs the patients likely carry the virus for life.

Clinical Presentation: CMV causes a wide variety of diseases from severe congenital infection to disseminated disease in the immunosuppressed. CMV infections can occur anywhere in the alimentary canal with the esophagus and colon being the most commonly affected sites. CMV colitis usually presents with diarrhea, which and be bloody or not, and abdominal pain. Rarely intestinal CMV infection causes a inflammatory mass that lead to intestinal obstruction and/or perforation. It is unusual for an immunocompetent patient to have CMV colitis. In the HIV population CMV infections occur which the CD4 count is less than 150.

Diagnosis: The diagnosis of CMV colitis can be suspected from the clinical history however it must be confirmed by biopsy. The infection is confirmed by identifying the typical cytopathic effect of the virus in conjunction with immunohistochemistry (see figure 1). Serology and viral cultures may have some utility.

Therapy: Ganciclovir with or without Foscarnet is the treatment for severe infections.

References:

  1. Koneman EW, Allen SD, Janda WM, Schreckenberger PC and Winn, Jr. WC (eds). Color Atlas and Textbook of Diagnostic Microbiology. pp 1211-1212, 5th ed. Lippincott, New York 1997.
  2. Wilson JD, Braunwald E, Isselbacher KJ, Petersdorf RG, Martin JB, Fauci AS and Root RK (eds). Harrisons Principles of Internal Medicine. pp 692-694, 12th ed. McGraw-Hill, New York 1991.
  3. Wilcox CM, Chalasani N, Lazenby A, Schwartz DA. Cytomegalovirus colitis in acquired immunodeficiency syndrome: a clinical and endoscopic study. Gastrointest Endosc 1998 Jul;48(1):39-43.
  4. Kearney DJ, Steuerwald M, Koch J, Cello JP. A prospective study of endoscopy in HIV-associated diarrhea. Am J Gastroenterol 1999 Mar;94(3):596-602.
  1. Figure 1: Immunohistochemical stain for CMV in a colon biopsy from this patient. Note the multiple positive cells in the lamina propria (arrows). Inset shows the cytopathic effect (arrowhead) of CMV demonstrated on an H&E stained section.

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