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.