Can Enterovirus Cause Chronic Mild Colitis?
Enterovirus is not recognized as a cause of chronic mild colitis in current clinical guidelines, which focus on CMV, bacterial pathogens, and parasites as the primary infectious etiologies of chronic colitis in both immunocompetent and immunocompromised patients.
Evidence from Clinical Guidelines
The major infectious disease and gastroenterology guidelines do not identify enterovirus as a causative agent of chronic colitis:
The 2017 IDSA guidelines on infectious diarrhea comprehensively address viral, bacterial, and parasitic causes of diarrheal illness but do not mention enterovirus as a cause of chronic colitis 1. The guidelines specifically highlight norovirus as the most common viral cause of diarrheal outbreaks, but characterize it as causing acute, self-limited illness 1.
The 2021 ECCO guidelines on infections in IBD extensively discuss CMV colitis as a significant viral cause of colonic inflammation in immunocompromised patients, but make no reference to enterovirus 1. These guidelines emphasize that CMV is detected in 10-30% of steroid-refractory IBD patients and is associated with poor outcomes 1.
The 2025 British Society of Gastroenterology IBD guidelines similarly focus on CMV and Clostridioides difficile as the key infectious considerations in patients with worsening IBD symptoms, without mentioning enterovirus 1.
Enterovirus Characteristics and Clinical Presentation
The 2018 European recommendations for enterovirus diagnostics provide important context:
Enteroviruses colonize the throat and gut for weeks to months, and detection in these sites must be interpreted cautiously 1. This prolonged shedding does not necessarily indicate active disease.
Immunocompromised patients can shed enteroviruses in stools for years 1, but this represents viral persistence rather than chronic colitis.
Enterovirus infections typically manifest as aseptic meningitis, encephalitis, respiratory illness, hand-foot-mouth disease, or acute hemorrhagic conjunctivitis 1, not chronic colonic inflammation.
Research Evidence on Enterovirus and Chronic GI Disease
Limited research suggests enterovirus may play a role in some immunodeficiency-related enteropathy, but this is distinct from chronic colitis:
A 2012 review hypothesized that prolonged enteroviral infections in immunocompromised hosts might contribute to inflammatory enteropathy, but noted this was described only in sporadic cases and that protracted viral shedding was not always associated with GI symptoms 2.
A 2023 review on viral GI pathogens states that rotavirus, norovirus, and adenovirus cause non-bloody diarrhea and are associated with acute gastroenteritis, not chronic colitis 3.
A 1999 study in HIV patients found that enteric viral infections (including adenovirus, rotavirus, and coronavirus) were significantly associated with acute rather than chronic diarrhea (P = 0.004) 4.
Clinical Algorithm for Chronic Mild Colitis Workup
When evaluating chronic mild colitis, the evidence-based approach should prioritize:
Stool testing for bacterial pathogens (Salmonella, Shigella, Campylobacter, Yersinia, STEC) and C. difficile 1, 5
Colonic tissue biopsy for CMV via immunohistochemistry or PCR in immunocompromised patients or those with steroid-refractory disease 1. A minimum of 11 biopsies from the left colon in UC and 16 in CD is recommended 1.
Stool microscopy for ova and parasites based on travel history and risk factors 1
Consider non-infectious etiologies including medication effects, ischemia, and underlying IBD 1
Critical Pitfalls to Avoid
Do not attribute chronic colitis to enterovirus detection in stool, as prolonged fecal shedding is common and does not indicate causation 1.
Do not overlook CMV colitis in immunocompromised patients, which requires tissue diagnosis and has significant mortality if untreated 1.
In immunocompromised patients with chronic diarrhea, consider adenovirus colitis (diagnosed by light microscopy of colonic biopsies), which is associated with chronic rather than acute symptoms 4.