What questions should be asked when evaluating a patient with suspected Cytomegalovirus (CMV) colitis?

Key Questions for Evaluating Patients with Suspected CMV Colitis

When evaluating a patient with suspected cytomegalovirus (CMV) colitis, it is essential to focus on immunosuppression status, gastrointestinal symptoms, and risk factors, as these significantly impact morbidity and mortality outcomes.

Immunosuppression History

• Ask about HIV/AIDS status, as HIV-positive patients are at increased risk for severe CMV infections 1
• Inquire about organ transplantation history, particularly liver transplants (4.9% 10-year cumulative incidence of post-transplant CMV end-organ disease) and hematopoietic stem cell transplantation (15-25% incidence of CMV end-organ disease) 1
• Question about current immunosuppressive medications, especially corticosteroids, azathioprine, or methotrexate, which are significantly associated with CMV disease (OR: 1.95; 95% CI: 1.05–3.62) 1
• Ask about anti-TNF therapy, which is an independent risk factor for CMV colitis (OR: 11.13; 95% CI: 3.31–37.44) 1
• Determine if the patient has inflammatory bowel disease (IBD), as patients with IBD presenting with CMV colitis may experience up to seven times higher in-hospital mortality 1

Gastrointestinal Symptoms

• Ask about diarrhea, which is a common nonspecific symptom of CMV colitis 1
• Inquire about rectal bleeding, which may indicate colonic involvement 1
• Question about abdominal pain, particularly its location, severity, and duration 1
• Ask about weight loss, which may indicate chronic disease 1
• Determine if the patient has experienced fever, a common symptom in CMV infection 1, 2
• Ask about symptoms of bowel obstruction or perforation, which are severe complications requiring urgent surgical intervention 1

Risk Assessment for Severe Disease

• Determine if the patient has steroid-refractory disease, which is associated with higher prevalence of CMV disease 1
• Ask about recent antibiotic use, which may affect differential diagnosis 1
• Question about recent onset of symptoms, as sudden onset may suggest infectious colitis rather than IBD flare 1
• Ask about exposure to individuals with known CMV infection, as CMV is shed in bodily fluids 1
• Inquire about occupation, particularly if the patient works in childcare facilities, which increases risk of acquiring CMV infection 1

Differential Diagnosis Considerations

• Ask about symptoms of classical CMV viremia (pharyngitis, lymphadenopathy, splenomegaly), though these are usually absent in CMV colitis 1
• Question about recent respiratory infections, as upper respiratory tract infections can be associated with mesenteric lymphadenitis 3
• Ask about recent travel history, which may suggest other infectious causes 3
• Inquire about symptoms of other viral infections that may mimic or coexist with CMV (e.g., EBV, Coxsackievirus) 3, 4

Previous Diagnostic Tests and Treatments

• Ask about previous colonoscopies and findings, particularly if ulcerations with well-defined, punched-out appearance were noted (present in up to 80% of patients) 1
• Inquire about previous treatments for similar symptoms and their effectiveness 1
• Question about previous CMV testing and results, including blood serology (though this has limited diagnostic value) 1
• Ask about previous antiviral treatments and response 5

Warning Signs of Complications

• Ask about signs of toxic megacolon, fulminant colitis, or perforation, which require emergency surgical intervention 1
• Question about symptoms suggesting disseminated CMV infection, which would necessitate discontinuation of immunosuppressive therapy 1
• Inquire about symptoms of intestinal obstruction or severe abdominal pain, which may require emergency surgical assessment 1

Common Pitfalls to Avoid

• Remember that blood serology has no diagnostic value for CMV colitis, as CMV seroprevalence in adults is at least 70% 1
• Be aware that patients with CMV colitis usually do not present with classical CMV viremia symptoms 1
• Note that culturing CMV from a biopsy is insufficient for diagnosis without histopathological changes, as some immunocompromised patients may have positive cultures without clinical disease 1, 5
• Consider that CMV colitis can occur in immunocompetent individuals, though it is less common 6, 7