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doi:10.1111/jgh.12760
E D U C AT I O N A N D I M A G I N G
Gastrointestinal: Ogilvie’s syndrome: A rare complication of cytomegalovirus infection in an immunocompetent patient
Figure 1
Multiple large clean-based ulcers with well-defined border.
Figure 3
Histopathological features of cytomegalovirus enterocolitis.
Endoscopic findings of cytomegalovirus enterocolitis.
Ogilvie’s syndrome is a disorder characterized by the acute dilatation of the colon in the absence of any mechanical obstruction in the debilitated patient. We herein present a rare case of Ogilvie’s syndrome coincided with cytomegalovirus (CMV) infection occurring in pregnancy. A 38-year-old primigravida presented at 18 weeks estimated fetal gestational age with vaginal bleeding and was found to have intrauterine fetal death requiring uterine curettage. Her course was complicated by increasing abdominal discomfort, passage of mucous stools, and subfebrile temperature. Physical examination revealed generalized abdominal distention with mild tenderness and absent bowel sounds. Abdominal X-ray and computed tomography scan demonstrated diffuse dilatation of intestines and thickened colonic wall without evidence of mechanical obstruction, suggesting pseudo-obstruction. She was treated conservatively with nothing by mouth, intravenous fluids, and nasogastric and rectal tube decompression without improvement after 72 h. Therefore, a 2-mg of neostigmine was given intravenously. The patient yet continued to suffer from abdominal distention without appreciable clinical response. Given failure of medical treatment, a decompressive colonoscopy was performed without bowel preparation. The colonoscope reached the splenic flexure and revealed multiple large clean-based ulcers with well-defined border in the sigmoid colon (Figs 1,2, arrow). Based on endoscopic findings, ganciclovir was administered intravenously for the presumptive diagnosis of CMV infection resulting in significant improvement of abdominal symptoms in a few days. Histopathological examination of the mucosal biopsies showed superficial erosion with acute and chronic inflammation in the lamina propria and granulation tissue containing a cytomegalic cell with intranuclear inclusion confirmed by immunoperoxidase staining for CMV (Fig. 3). Additional laboratory showed absence of human immunodeficiency virus antibodies and normal determination for helper and cytotoxic T lymphocytes. The patient remained well, and colonic lesions were completely resolved on the follow-up colonoscopy at 6 months after discharge. 1752
Figure 2
Most of reported patients with CMV disease of the gastrointestinal tract suffered from severe life-threatening complications including profuse bleeding necessitating resection, toxic megacolon, and perforation. There are few reported cases of CMV infection associated with Ogilvie’s syndrome, and they are mostly confined to transplant recipients. The precise mechanism by which colonic dysmotlity occurs in CMV infection remains unknown. Nonetheless, infection of the myenteric plexus could lead to an imbalance in the autonomic innervation of the colon, which may be augmented by an increased sympathetic drive in an ill patient, resulting in acute colonic pseudo-obstruction. Early diagnosis and appropriate treatment for CMV-related colonic dilatation may result in faster recovery and avoid complications. Contributed by P Charatcharoenwitthaya,* N Pausawasdi* and A Pongpaibul† *Division of Gastroenterology, Department of Medicine, and † Department of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
Journal of Gastroenterology and Hepatology 29 (2014) 1752 © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
doi:10.1111/jgh.12760
E D U C AT I O N A N D I M A G I N G
Gastrointestinal: Ogilvie’s syndrome: A rare complication of cytomegalovirus infection in an immunocompetent patient
Figure 1
Multiple large clean-based ulcers with well-defined border.
Figure 3
Histopathological features of cytomegalovirus enterocolitis.
Endoscopic findings of cytomegalovirus enterocolitis.
Ogilvie’s syndrome is a disorder characterized by the acute dilatation of the colon in the absence of any mechanical obstruction in the debilitated patient. We herein present a rare case of Ogilvie’s syndrome coincided with cytomegalovirus (CMV) infection occurring in pregnancy. A 38-year-old primigravida presented at 18 weeks estimated fetal gestational age with vaginal bleeding and was found to have intrauterine fetal death requiring uterine curettage. Her course was complicated by increasing abdominal discomfort, passage of mucous stools, and subfebrile temperature. Physical examination revealed generalized abdominal distention with mild tenderness and absent bowel sounds. Abdominal X-ray and computed tomography scan demonstrated diffuse dilatation of intestines and thickened colonic wall without evidence of mechanical obstruction, suggesting pseudo-obstruction. She was treated conservatively with nothing by mouth, intravenous fluids, and nasogastric and rectal tube decompression without improvement after 72 h. Therefore, a 2-mg of neostigmine was given intravenously. The patient yet continued to suffer from abdominal distention without appreciable clinical response. Given failure of medical treatment, a decompressive colonoscopy was performed without bowel preparation. The colonoscope reached the splenic flexure and revealed multiple large clean-based ulcers with well-defined border in the sigmoid colon (Figs 1,2, arrow). Based on endoscopic findings, ganciclovir was administered intravenously for the presumptive diagnosis of CMV infection resulting in significant improvement of abdominal symptoms in a few days. Histopathological examination of the mucosal biopsies showed superficial erosion with acute and chronic inflammation in the lamina propria and granulation tissue containing a cytomegalic cell with intranuclear inclusion confirmed by immunoperoxidase staining for CMV (Fig. 3). Additional laboratory showed absence of human immunodeficiency virus antibodies and normal determination for helper and cytotoxic T lymphocytes. The patient remained well, and colonic lesions were completely resolved on the follow-up colonoscopy at 6 months after discharge. 1752
Figure 2
Most of reported patients with CMV disease of the gastrointestinal tract suffered from severe life-threatening complications including profuse bleeding necessitating resection, toxic megacolon, and perforation. There are few reported cases of CMV infection associated with Ogilvie’s syndrome, and they are mostly confined to transplant recipients. The precise mechanism by which colonic dysmotlity occurs in CMV infection remains unknown. Nonetheless, infection of the myenteric plexus could lead to an imbalance in the autonomic innervation of the colon, which may be augmented by an increased sympathetic drive in an ill patient, resulting in acute colonic pseudo-obstruction. Early diagnosis and appropriate treatment for CMV-related colonic dilatation may result in faster recovery and avoid complications. Contributed by P Charatcharoenwitthaya,* N Pausawasdi* and A Pongpaibul† *Division of Gastroenterology, Department of Medicine, and † Department of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
Journal of Gastroenterology and Hepatology 29 (2014) 1752 © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
