Discussion
CMV infections are becoming more prevalent in immunocompetent patients.5 Recently, with the outbreak of Coronavirus disease (COVID-19), many studies have suggested that COVID-19 may activate dysregulated host immune responses, where interleukin-6 (IL-6) levels are elevated in cases of severe COVID-19, so the anti-IL-6 such as tocilizumab may be beneficial. 6 however, the available evidence still not conclusive that tocilizumab is beneficial to patients with severe COVID-19 and not yet recommended for routine clinical guidelines.
Al-Omari et al. noted that the risk factors such as the immunocompromised, mechanical ventilation, sepsis were found to be strongly associated with CMV. In contrast, the use of corticosteroids, blood transfusion and stress were weakly associated. They found no association with risk factors such as age, gender, disease severity scores, and active malignancy. 7
It demonstrates an organ-specific tropism within the body affecting mainly hemopoietic stem cells and parenchymal connective tissue. As per the systemic review done by Rafailidis et al., in immunosuppressed patients with tissue-invasive (TI) CMV, the gastrointestinal tract is the most commonly affected and comprises almost 30% of the disease.5 CMV lesions may be present throughout the gastrointestinal tract, from the oral cavity to the rectum. However, colon involvement is the most common, comprising up to 94% of cases.8-10 For viral reactivation in the immunocompetent, critical illness is a major predisposing factor for developing TI-CMV disease. 11
Endoscopic findings of CMV colitis, like ulcers and inflammation, are similar to UC exacerbation. Biopsies that reveal CMV inclusion bodies in the pathological specimen may be the only way to distinguish between IBD and CMV. The presence of CMV infection in our patient was diagnosed only based on the presence of inclusion bodies. Biopsy with Immunohistochemistry using monoclonal antibodies against CMV antigens is now considered the gold standard. 12 The characteristic Owl’s eye inclusion bodies are highly specific for CMV.13 CMV colitis and IBD closely mimics each other in their clinical, endoscopic and histological appearance. Therefore, it is crucial to avoid misdiagnosis and mismanagement, keeping in mind the high morbidity associated with it.