Cytomegalovirus Colitis Presenting as a Rectal Mass

Sir,

I read with great interest the article entitled, “Cytomegalovirus colitis presenting as a rectal mass” by Cohen et al.,[1] which was published in your esteemed journal. It is an unusual and interesting case. In this connection, I have a few observations.

First, as this is a case report dealing with cytomegalovirus (CMV) colitis presenting as a rectal mass mimicking adenocarcinoma and causing rectal prolapse, it is a preferable to have a photograph or image of the rectal prolapse for the particular case for better understanding.

Second, while reporting a case, it is better to mention case history including physical examination and laboratory investigations in detail. In this particular case, the authors should have at least mentioned about physical examination, particularly the examination of the eye to look for CMV retinitis. As retinitis may coexist with gastrointestinal disease and can alter the duration of antiviral treatment if present.[2] In addition, the site of infection should be carefully followed up to ensure remission, thereby preventing blindness.[3] It is also worth to mention about CD4 counts. As this typically occurs in patients with CD4 counts below 150 cell/mm3.[4]

Third, the authors have used 450 mg valganciclovir successfully in the index case. However, I would like to state that two 450 mg tablets orally result in the blood level that is equivalent to those attained with intravenous ganciclovir at a dose of 5 mg/kg/day.[5] It has been mentioned in the 10th edition of Sleisenger and Fordtran’s Gastrointestinal and Liver Disease (2016) that valganciclovir (an oral prodrug of ganciclovir) has an excellent gastrointestinal absorption and efficacy for CMV retinitis, but has not been well studied for induction therapy in gastrointestinal disease.[3]

• References

• 1 Cohen AJ, Kumar NL, McNabb-Baltar JY. Cytomegalovirus colitis presenting as a rectal mass. J Dig Endosc 2017; 8: 137-9
• 2 Wilcox CM. Esophageal infections and disorders associated with acquired immunodeficiency syndrome. In: Podosky DK, Camilleri M, Fitz JG, Kallo AN, Shanahan F, Wang TC. editors Yamada’s Textbook of Gastroenterology. West Sussex, UK: Wiley Blackwell; 2016: p. 937-48
• 3 Wilcox CM. Gastrointestinal consequences of infection with human immunodeficiency virus.. In: Feldman M, Friedman LS, Brandt LJ. editors Sleisenger and Fordtran's Gastrointestinal and Liver Disease. Philadelphia, PA: Elsevier Saunders; 2016: p. 542-54
• 4 Karakozis S, Gongora E, Caceres M, Brun E, Cook JW. Life-threatening cytomegalovirus colitis in the immunocompetent patient: Report of a case and review of the literature. Dis Colon Rectum 2001; 44: 1716-20
• 5 Crumpacker 2nd CS. Ctomegalovirus (CMV). In: Bennett JE, Dolin R, Blaser MJ. editors Mandell, Douglas and Bennettfs Principles and Practice of Infectious Diseases. Philadelphia: Elsevier Saunders; 2015: p. 1738-53