HERPETIC COLITIS CAUSING LOWER GI BLEEDING IN A PATIENT UNDERGOING CHEMOTHERAPY P Oakes MD, M Modica MD Department of Internal Medicine, LSU Health, New Orleans, LA
INTRODUCTION: Herpes simplex virus (HSV) is a ubiquitous double-stranded DNA virus that can cause a multitude of pathological manifestations. Herpetic colitis is a rare manifestation of the herpes simplex virus that has been mostly documented in patients suffering from inflammatory bowel disease who are being treated with immunosuppressive therapies. Use of these medications cause an exogenous immunosuppression that can lead to reactivation of a latent infection. CASE: A 66-year-old male with a past medical history of colorectal cancer treated with resection and chemotherapy presents with acute encephalopathy. On admission, the patient was febrile and tachypneic. The patient was treated with antibiotics for a Candida albicans urinary tract infection (UTI) and Staphylococcus epidermidis bacteremia. During the hospitalization, the patient experienced bloody output in his colostomy bag and a decrease in hemoglobin requiring a blood transfusion. The patient underwent an esophagogastroduodenoscopy and had two angioectasias cauterized. Approximately two weeks later, the patient experienced another episode of bloody ostomy output. The patient underwent a small bowel enteroscopy and had a duodenal angioectasia treated. Unfortunately, the patient continued to express blood-tinged stool via his ostomy and underwent a video capsule endoscopy. After eight hours, the capsule failed to advance further than the esophagus and was deemed inconclusive. The patient then underwent a colonoscopy. During the procedure, multiple areas of nodularity, friability, and ulceration were biopsied. The specimens demonstrated ulcerated mucosa with enlarged amorphous inflammatory cells suggestive of a cytopathic effect that was positive for HSV. This finding was consistent with herpetic colitis. The patient was treated with valacyclovir twice daily for fourteen days and did not suffer any more episodes of bloody ostomy output. He was eventually discharged to a skilled nursing facility. DISCUSSION: Herpetic colitis is a rare condition that has a small presence in the literature. Symptoms are variable, and can include bloody diarrhea, abdominal discomfort, fever, arthralgias, and weight loss. Immunofluorescence staining or PCR is the method of diagnosis. Treatment consists of administration of an antiviral nucleoside analog such as valacyclovir. As herpetic colitis is a rare cause of lower gastrointestinal bleeding, healthcare providers should familiarize themselves with the visceral manifestations of HSV, susceptible populations, diagnosis, and management.
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