1904 Multiple Facets of CMV-Related Gastrointestinal Disease: From Top to Bottom

Abstract

INTRODUCTION: Cytomegalovirus (CMV) primarily affects immunocompromised patients, and has multiple manifestations in the gastrointestinal (GI) tract. The incidence of CMV-related GI disease has decreased since the advent of antiretroviral therapy (ART) for HIV. This, along with varied and nonspecific symptoms, makes it difficult to diagnose. CASE DESCRIPTION/METHODS: We report a 34-year-old man with AIDS (CD4 count 114 cells/µL) on ART presenting with five days of fevers. He was admitted to the ICU for sepsis and stabilized. His course was complicated by pulmonary embolism, recurrent fevers, and development of biopsy proven pyoderma gangrenosum. He also reported odynophagia, and was empirically treated for candida esophagitis with fluconazole. On hospital day 37, he developed massive hematochezia. An urgent esophagogastroduodenoscopy (EGD) did not reveal the source of bleeding, but showed a 5-cm linear esophageal scar, which appeared to be a healing tear. Sigmoidoscopy revealed a solitary rectal ulcer with a visible vessel, which was clipped for hemostasis. His bleeding resolved. The patient’s odynophagia persisted, significantly limiting his ability to tolerate oral intake. Repeat EGD revealed a large, cratered, non-bleeding esophageal ulcer which was biopsied. The same day, the patient developed hematochezia; repeat sigmoidoscopy showed a deeply cratered rectal ulcer with a visible vessel successfully treated with hemostatic clips. Esophageal biopsies returned positive for CMV; valganciclovir was initiated. His odynophagia improved after starting treatment and he had no further GI bleeding. Given the clinical response, the rectal ulcers were presumed to be due to CMV, making this a case of extensive CMV-related GI disease. DISCUSSION: This is a case of extensive CMV-related GI disease which eluded diagnosis during a prolonged and complicated hospitalization. CMV-related GI disease has varied presentations, most commonly affecting the esophagus, but has also been noted to manifest with gastritis, duodenitis, pancreatitis, and colitis. The most common endoscopic findings for esophageal involvement are discrete, shallow, punched-out ulcers surrounded by normal appearing mucosa. Clinical manifestations of colonic CMV include abdominal pain and diarrhea, while discrete ulceration causing bleeding is less commonly reported. This case highlights the importance of a high index of suspicion for CMV in immunocompromised patients with multiple, unexplained GI symptoms to avoid a delay in diagnosis and management.