Misdiagnosis of specific cytomegalovirus infection of the ileoanal pouch as refractory idiopathic chronic pouchitis - Report of two cases

PURPOSE: Chronic nonspecific reservoir ileitis (pouchitis) occurs in 5 to 1 0 percent of patients who undergo ileal pouch-anal anastomosis for ulcerati ve colitis. Specific infection of the ileal pouch-anal anastomosis with cyt omegalovirus has not been reported. AIM: We report two patients with specif ic cytomegalovirus infection of the ileal pouch-anal anastomosis, initially misdiagnosed as idiopathic chronic pouchitis. CASE SERIES: Patient 1 had i leal pouch-anal anastomosis for ulcerative colitis. Three years later she h ad diarrhea, fever, pelvic pain, and pouch inflammation at endoscopy consis tent with pouchitis. She had no response to medical therapy. Repeat endosco py showed persistent inflammation and biopsies showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 1 0 mg/kg/day for ten days (stopped for rash). Repeat pouch biopsies were neg ative for cytomegalovirus. Patient 2 had ileal pouch-anal anastomosis for u lcerative colitis. Nine years later she had resection of obstructing struct ure at previous loop ileostomy site. She underwent reoperation with ileosto my and pouch defunctionalization for peritonitis. Four weeks later she had fever and bloody discharge from the diverted pouch. Pouch endoscopy with bi opsy showed inflammation consistent with pouchitis. She had no response to medical therapy. Re-examination of pouch biopsies with a specific monoclona l immunofluorescent stain showed cytomegalovirus, She had symptomatic impro vement after treatment with intravenous ganciclovir, 10 mg/kg/day for 21 da ys. Repeat pouch biopsies were negative for cytomegalovirus. CONCLUSIONS: S pecific cytomegalovirus infection of the ileal pouch-anal anastomosis may b e misdiagnosed as idiopathic refractory chronic pouchitis. Cytomegalovirus must be excluded before immune modifier therapy or pouch excision in these patients.