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Background: Cytomegalovirus (CMV) colitis is commonly seen in patients who are immunodeficient or have inflammatory bowel disease. Among the gastrointestinal sites affected by CMV, the colon is the most frequently affected, though rectal involvement is relatively rare. Reactivated CMV proctitis primarily occurs in elderly patients with comorbidities and is quite uncommon in immunocompetent individuals. Patients with reactivated CMV typically present with symptoms such as diarrhea, hematochezia, or tenesmus. Case presentation: We report a case of a female patient with uncontrolled diabetes who presented to the clinic complaining of perianal pain. She had no history of diarrhea or rectal bleeding. Lower GI endoscopy reported a small, localized, approximately 0.5 cm swelling in the proximal anal canal in addition to sigmoid diverticulosis. The biopsy revealed a small ulcer at the anorectal junction caused by CMV and confirmed by immunohistochemistry. Unfortunately, the patient was lost to follow-up before antiviral therapy could be initiated. Conclusions: This case highlights an uncommon presentation of reactivated CMV proctitis in an older diabetic patient presenting solely with perianal pain. Clinicians should maintain a high index of suspicion for CMV infection in elderly patients with comorbidities, even when classical colitis symptoms are absent, to avoid delayed diagnosis and management. Full article

(1) Background: We describe a case of a 58-year-old Chinese woman, without obvious cause of immunosuppression, who developed cytomegalovirus (CMV) proctitis three days after a second COVID-19 vaccination. Electronic colonoscopy revealed a new lesion that was circumferential at the anorectal junction, with an uneven surface and ulceration, which mimicked rectal carcinoma. This is the first case of CMV proctitis following vaccination since the invention of the COVID-19 vaccine, suggesting that the COVID-19 vaccine may cause disorders of immune homeostasis, including not only immune hyperactivity but also immune deficiency. We report this case to increase readers’ awareness of the risks after COVID-19 vaccination and to provide new ideas for the diagnosis and treatment of similar cases. (2) Methods: In this case, we used laboratory biochemical examinations, colonoscopy, immunohistochemistry, and a biochemical index to confirm the existence of CMV proctitis. (3) Results: In this case, the vaccine-induced CMV proctitis had a similar endoscopic appearance to rectal neoplastic lesions, which could be confirmed by biopsy and quickly relieved by ganciclovir treatment. Ganciclovir was used to treat the patient, and a good effect was observed. (4) Conclusions: COVID-19 vaccination may cause immune disorders, not just immune hyperactivity as previously reported, but also immune deficiency, such as CMV proctitis in this case. The clinical course of CMV proctitis secondary to COVID-19 vaccination was favorable with ganciclovir therapy. Full article