Introduction

 Cytomegalovirus (CMV) is a common virus, especially in developing countries (1). CMV usually affects patients with chronic immunosuppressive diseases (HIV, leukemia) or immunosuppressive drugs for the treatment of autoimmune diseases or cancers. CMV infection may also affect immunocompetent patient with no history of chronic disease (2). CMV infection in immunocompetent hosts range from asymptomatic to CMV-induced mononucleosis, pneumonitis, hepatitis, fever, tiredness, sore throat,  vomiting , muscle and joint pain, loss of appetite , esophagitis and colitis . In congenital infection the symptom include , jaundice,  pneumonia, rash consisting of small, purplish spots , enlarged liver and spleen,  low birth weight , seizures  and small head . CMV infection is due to  hearing loss during childhood. The treatment of CMV infection  is depends on the type and severity of symptoms and immunity of patient and anti-viral drugs such as ganciclovir should be prescribed (2-3).

 Our patient was a 20 month girl with bloody diarrhea so that her colonoscopy showed CMV infection  then treated well with ganciclovir without any complication.

Case Report

A 20 month old girl with chronic bloody diarrhea admitted 4 month ago to GI ward. She was the first child of family with birth weight 3kg and height 55cm. . she has admitted to the hospital several times for diarrhea and poor weight gain during last 4 month. In the admission, her weight and height were under 5 Th percentile for her age. She had 10-12 times bloody diarrhea per day that her mother was so irritable. The patient   was so ill and dehydrate. . In the physical examination we did not find any significant clue such as fever, organomegaly, skin rash, trush and the anus was normal with no fissure or ulcer.  The Laboratory investigations showed a leukocytosis (WBC=20000, PMN=40%), Hb=7.5 g/dl, Plt=165000, Na=130, K=3.4, Mg=2, Ca=8, P=3.8, BUN=29, Cr= 1, AST=23, ALT=34, ALP=890, Alb=3, PT=12, INR=1, PTT=32. U/A and U/C were normal. Many WBC and RBC was detected in S/E. S/C was normal with no organism. Abdominal sonography, chest x ray and PPD test were normal. After hydration therapy with normal saline for infant and stabilization, colonoscopy was done. Colonoscopy was performed up to Ileum. The anus up to ascending colon just have mild nodular lymphoid hyperplasia (NLH) but the cecum has a deep large ulcer with irregular margin with debris and erythema, multiple biopsies were taken from ulcer and cecum and sent to the laboratory for investigate the TB, CMV, TOXO, EBV by PCR. After colonoscopy, the serum HIV, CMV, EBV were checked. HIV, TOXO , TB, EBV tests and IgG electrophoresis were normal, NBT was 100% and fungal infection was role out but PCR CMV in tissue and serum were positive and confirmed CMV infection in infant. Histopathology examination revealed severe active colitis, with multiple deep ulcers and focal subserosa fibrosis. The surrounding mucosa demonstrated regenerative change. The patient was treated with intravenous gancyclovir for two weeks and then with oral valgancyclovir for additional four weeks. Her diarrhea settled within a few days of initial treatment. Her blood studies was normalized. The patient remained asymptomatic during 2 month of follow-up with weight gain.

Discussion

Human cytomegalovirus (CMV) is a member of herpes virus subfamily, which also includes the HHV 6 (Human herpes virus 6).  Infection with CMV is generally asymptomatic in healthy children and adults. The risk factors for CMV infection are organ transplantation , bone marrow transplantation , HIV , chemotherapy , radiation and use of immunosuppressive drugs such as corticosteroid. (4-5). CMV is also a major cause of morbidity and occasional mortality in newborn infants. The risk of congenital cytomegalovirus (CMV) infection is not well defined in the developing world. Both sexes are equally susceptible to infection and morbidity from cytomegalovirus (CMV) (5). The colon is the most commonly affected region of GI tract, but we can see CMV in esophagus or stomach. The most commonly colonoscopy features of CMV colitis are multiple ulcers with persistent inflammation and fibrotic changes followed by large and deep ulcers in the colon resulting in lumen stricture (6-7). CMV organism may be detected with H&E stain.  Direct specific immunofluorescent antibody detects viral antigens or viral DNA can show the infection (7-8). Patients who are not immunosuppressed should be treated with antiviral agents such as Ganciclovir (Cytovene) and Foscarnet (Foscavir)(9-10). CMV colitis, although rare in immunocompetent patients but it should be considered when the patients have severe diarrhea or bloody stool. Colonoscopy or endoscopy should be done with taken multiple biopsies for finding infection in tissue (10-11).

Our infant with chronic bloody diarrhea and FTT diagnosed as CMV colitis and treated with ganciclovir, so her symptom resolved without any complication and she has a weight gain after treated. We recommended that patients with chronic GI manifestation should be evaluated for CMV and other infection because these infections in immunocompetent patients cure without any complication.

Conflict of interests: None.