Severe Colonic Stricture in Immunosuppressed Patient With Chronic CMV Colitis

To the Editor: We would like to alert the reader to the problem of colonic strictures associated with cytomegalovirus (CMV) in patients on immunosuppression, in this case related to bone marrow transplantation (BMT). A 6-year-old boy with chronic granulomatous disease (CGD), previously treated with BMT twice, developed several months of bloody diarrhea, fever, and abdominal pain. Upper endoscopy and flexible sigmoidoscopy revealed epithelial damage, but no chronic inflammatory changes or evidence of graft-versus-host disease. Tissue polymerase chain reaction (PCR) was positive for CMV. Symptoms resolved with treatment, but CMV-PCR remained positive. Two months later, he developed episodic diffuse abdominal pain. Computed tomography scan demonstrated a long segment of submucosal colonic wall thickening. Barium enema reproduced the pain and revealed a pinpoint focal colonic stricture at the splenic flexure. Surgical resection of 20 cm colon revealed ulceration with chronic inflammation with cytopathic changes consistent with CMV. Although BMT can be curative for CGD, chronic immunosuppression places patients at higher risk for disseminated infections (1,2). CMV is an opportunistic pathogen causing systemic disease through invasion of endothelial cells, commonly in the GI tract (3–5). Colonic strictures have been reported both in association with CMV (3,5) and CGD in up to 24% of patients (4,6). Enteritis obliterans is another consideration although the pathology was not suggestive. In addition to surgical options, endoscopic management of colonic strictures with dilation and stenting can also be considered, with one systematic review of patients with Crohn disease reporting high success rates especially for strictures <5 cm in length (7).