Concomitant CMV and Clostridium di cile colitis in an immunocompetent patient treated with Ganciclovir and fecal transplantation

A 53-year-old patient, recently operated for duodenal ulcer, was admitted to the Clinic of Gastroenterology, Clinical Emergency and County Hospital, Constanta, presenting watery diarrhea (about 12 stools/day), abdominal pain, weight loss, nausea and altered general condition. e symptoms appeared three months ago, a er prolonged treatment with cipro oxacine for a urinary infection associated with catheter during previous surgery. e patient was diagnosed with Clostridium di cile colitis based on positive test for toxin A + B (immunochromatographic method) and colonoscopy, which revealed the presence of pseudomembranous colitis. During this period, he had received treatment several times with metronidazole 1500 mg/day (intravenous or orally) associated with oral vancomycin 250 mg every 6 h, and then 500 mg every 6 h and rifaximin 1200mg/day, but no signi cant improvements were observed. On admission, laboratory analyses revealed anemia (Hb = 9.3 g/dl), neutrophilic leukocytosis (L = 17.6x103 μL, neutrophils = 82.7%), positive in ammatory tests (PCR = 12 mg/dl, normal value < 0.5 mg/dl) and hypoalbuminemia. Abdominal ultrasound and CT showed normal liver, distended bowel loops with thickened wall and ascites uid in the abdominal cavity. The tests excluded liver disease (normal aminotransferases, HBsAg-negative, anti-HCVnegative, normal AFP, normal electrophoresis), enterocolitis with other etiology (negative coprocultures for Salmonella, Shigella, Campylobacter, Escherichia coli enterohemoragic O157:H7), negative HIV test, positive CMV IgG ( >500 U/ ml, N = < 9 U/ml) and positive CMV IgM (14.17 U/ml (N < 9 U/ml). Biopsy prelevated at colonoscopy showed endothelial and stromal cells with enlarged smudgy nuclei containing basophilic inclusion bodies characteristic for Cytomegalovirus colitis (Figs.1, 2). Our diagnosis was reactivation of latent CMV infection in conditions of immunosuppression caused by pseudomembranous colitis. We performed fecal transplantation and subsequent treatment with Ganciclovir LETTERS TO THE EDITOR