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Portal venous gas and pneumatosis coli in severe cytomegalovirus colitis A previously healthy 32-year-old Australian man of Asian descent presented to the emergency department in septic shock, manifested by fever to 39.5°C, tachycardia to 140 per minute and a respiratory rate of 30 per minute. History revealed two days of fever and rigors before developing profuse diarrhoea and vomiting. The abdomen was severely tender in the right iliac fossa, with hyperactive bowel sounds. Initial laboratory investigations revealed an elevated venous lactate of 3.5 mmol/L and C-reactive protein of 81.8 mg/L, with a normal white cell count (8.2 × 109/L) and neutrophilia of 7.7 × 109/L. Computed tomography (CT) demonstrated pneumatosis of the ascending colon (Fig. 1) with patent mesenteric vessels and portal venous gas (Fig. 2), reported as possible bowel ischaemia. Urgent diagnostic laparoscopy was performed to ascertain the status of the bowel, with intention to convert the procedure to a laparotomy if gangrenous bowel was detected. There was marked hyperaemia of the ascending colon and dilatation of the small bowel to approximately 4 cm. There was no evidence of small or large bowel obstruction or of gangrenous bowel. Appendicectomy was performed as a prophylactic measure to eliminate the possibility of future appendicitis in the setting of severe colitis of the ascending colon and caecum.
Intravenous antibiotics (ceftriaxone, gentamicin and metronidazole) were commenced. Clinical improvement from the state of severe sepsis was apparent in the first 48 h. On day three of admission, colonoscopy was performed which revealed extensive mucosal necrosis in the ascending colon (Fig. 3), corresponding to the site of pneumatosis on CT scan. Biopsies revealed a focal area of nuclear inclusions indicative of cytomegalovirus infection. Viral serology
Fig. 2. Portal venous gas (arrow).
Fig. 1. Pneumatosis of the ascending colon (arrow).
© 2015 Royal Australasian College of Surgeons
Fig. 3. Mucosal necrosis of the ascending colon, corresponding with pneumatosis on computed tomography.
ANZ J Surg •• (2015) ••–••
2
was positive for cytomegalovirus antibodies. Blood and stool cultures including Clostridium difficile were negative. The patient improved and was discharged after 7 days with plan for repeat colonoscopy to assess resolution. Incidental benign pneumatosis intestinalis has been well described previously;1 however, when pneumatosis is associated with an acute abdomen and severe sepsis, ischaemic bowel should be considered. The presence of portal venous gas is further suggestive of portal pyemia secondary to bowel ischaemia,2 with secondary bacterial infection. Severe cytomegalovirus colitis in the immunocompetent host is more prevalent than initially thought.3,4 In the presence of an acute abdomen and profuse diarrhoea, it should be considered as a differential diagnosis, as it carries significant morbidity and mortality.4 CT findings of distal colonic wall thickening, later diagnosed as cytomegalovirus colitis on sigmoidoscopy, was reported in 2005.5 This, however, appears to be the first reported case of severe cytomegalovirus colitis associated with both portal venous gas and pneumatosis coli.
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2. Kernagis LY, Levine MS, Jacobs JE. Pneumatosis intestinalis in patients with ischaemia: correlation of CT findings with viability of the bowel. Am. J. Roentgenol. 2003; 180: 733–6. 3. Klauber E, Briski LE, Khatib R. Cytomegalovirus colitis in the immunocompetent host: an overview. Scand. J. Infect. Dis. 1998; 30: 559–64. 4. Lancini D, Faddy HM, Flower R, Hogan C. Cytomegalovirus in immunocompetent adults. Med. J. Aust. 2014; 201: 578–80. 5. Siegal DS, Hamid N, Cunha BA. Cytomegalovirus colitis mimicking recurrent inflammatory bowel disease: report of three cases. Am. Surg. 2007; 73: 58–61.
Hasitha Dinesh Balasuriya, MBBS Jayantha Abeysinghe, MBBS, FRACS Nicholas Cocco, LLB, MBBS Department of Surgery, Canterbury Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.13224
References 1. Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life-threatening causes. Am. J. Roentgenol. 2007; 188: 1604–13.
© 2015 Royal Australasian College of Surgeons
Portal venous gas and pneumatosis coli in severe cytomegalovirus colitis A previously healthy 32-year-old Australian man of Asian descent presented to the emergency department in septic shock, manifested by fever to 39.5°C, tachycardia to 140 per minute and a respiratory rate of 30 per minute. History revealed two days of fever and rigors before developing profuse diarrhoea and vomiting. The abdomen was severely tender in the right iliac fossa, with hyperactive bowel sounds. Initial laboratory investigations revealed an elevated venous lactate of 3.5 mmol/L and C-reactive protein of 81.8 mg/L, with a normal white cell count (8.2 × 109/L) and neutrophilia of 7.7 × 109/L. Computed tomography (CT) demonstrated pneumatosis of the ascending colon (Fig. 1) with patent mesenteric vessels and portal venous gas (Fig. 2), reported as possible bowel ischaemia. Urgent diagnostic laparoscopy was performed to ascertain the status of the bowel, with intention to convert the procedure to a laparotomy if gangrenous bowel was detected. There was marked hyperaemia of the ascending colon and dilatation of the small bowel to approximately 4 cm. There was no evidence of small or large bowel obstruction or of gangrenous bowel. Appendicectomy was performed as a prophylactic measure to eliminate the possibility of future appendicitis in the setting of severe colitis of the ascending colon and caecum.
Intravenous antibiotics (ceftriaxone, gentamicin and metronidazole) were commenced. Clinical improvement from the state of severe sepsis was apparent in the first 48 h. On day three of admission, colonoscopy was performed which revealed extensive mucosal necrosis in the ascending colon (Fig. 3), corresponding to the site of pneumatosis on CT scan. Biopsies revealed a focal area of nuclear inclusions indicative of cytomegalovirus infection. Viral serology
Fig. 2. Portal venous gas (arrow).
Fig. 1. Pneumatosis of the ascending colon (arrow).
© 2015 Royal Australasian College of Surgeons
Fig. 3. Mucosal necrosis of the ascending colon, corresponding with pneumatosis on computed tomography.
ANZ J Surg •• (2015) ••–••
2
was positive for cytomegalovirus antibodies. Blood and stool cultures including Clostridium difficile were negative. The patient improved and was discharged after 7 days with plan for repeat colonoscopy to assess resolution. Incidental benign pneumatosis intestinalis has been well described previously;1 however, when pneumatosis is associated with an acute abdomen and severe sepsis, ischaemic bowel should be considered. The presence of portal venous gas is further suggestive of portal pyemia secondary to bowel ischaemia,2 with secondary bacterial infection. Severe cytomegalovirus colitis in the immunocompetent host is more prevalent than initially thought.3,4 In the presence of an acute abdomen and profuse diarrhoea, it should be considered as a differential diagnosis, as it carries significant morbidity and mortality.4 CT findings of distal colonic wall thickening, later diagnosed as cytomegalovirus colitis on sigmoidoscopy, was reported in 2005.5 This, however, appears to be the first reported case of severe cytomegalovirus colitis associated with both portal venous gas and pneumatosis coli.
Images for surgeons
2. Kernagis LY, Levine MS, Jacobs JE. Pneumatosis intestinalis in patients with ischaemia: correlation of CT findings with viability of the bowel. Am. J. Roentgenol. 2003; 180: 733–6. 3. Klauber E, Briski LE, Khatib R. Cytomegalovirus colitis in the immunocompetent host: an overview. Scand. J. Infect. Dis. 1998; 30: 559–64. 4. Lancini D, Faddy HM, Flower R, Hogan C. Cytomegalovirus in immunocompetent adults. Med. J. Aust. 2014; 201: 578–80. 5. Siegal DS, Hamid N, Cunha BA. Cytomegalovirus colitis mimicking recurrent inflammatory bowel disease: report of three cases. Am. Surg. 2007; 73: 58–61.
Hasitha Dinesh Balasuriya, MBBS Jayantha Abeysinghe, MBBS, FRACS Nicholas Cocco, LLB, MBBS Department of Surgery, Canterbury Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.13224
References 1. Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life-threatening causes. Am. J. Roentgenol. 2007; 188: 1604–13.
© 2015 Royal Australasian College of Surgeons
