Overlapping Cytomegalovirus Infection and Inflammatory Pouchitis After Liver Transplantation: When Antivirals Alone Are Insufficient.

Cytomegalovirus (CMV) is an infrequently reported etiology of secondary pouchitis in patients who have undergone total proctocolectomy with ileal pouch-anal anastomosis. We present the case of a patient with chronic antibiotic-dependent pouchitis, ulcerative pancolitis, primary sclerosing cholangitis, and orthotopic liver transplant who presented with hematochezia. Pouchoscopy showed ulcerated mucosa, and histopathology with immunohistochemistry confirmed CMV pouchitis. The patient was treated with antiviral therapy with improvement in bleeding and viremia. However, persistent refractory pouch inflammation ultimately required guselkumab. This case depicts the importance of considering CMV as a secondary etiology of pouchitis, especially in those with refractory or atypical features.