2529 A Case of Cytomegalovirus Causing Duodeno-Colonic Fistula in Immune Competent Patient

Abstract

INTRODUCTION: Cytomegalovirus (CMV) is a common opportunistic infection in immune compromised patients. Within the gastro-intestinal tract, it is a known cause of esophagitis and colitis. A rare presentation of CMV infection is an enteric fistula with only a few cases reported. We present a case of duodena-colonic fistula secondary to CMV in an immune competent host. CASE DESCRIPTION/METHODS: 86-year gentleman with past medical history of dementia who presented with complaints of feeling tired, jaundice and colorless diarrhea, significant weight loss for two months. He denied alcohol use and was not taking any prescription medications. He denied family history of cancer or liver disease. His initial labs showed non-specific elevation in the liver enzymes along with mild anemia. He underwent an MRI abdomen that showed duodenal swelling but no obstructive mass or bile duct dilation. Endoscopic ultrasound showed a large duodenal ulcer with duodena-colonic fistula that was large enough for the scope to pass through. Biopsies were taken from the fistula and liver which showed cytoplasmic inclusion bodies characteristic of CMV. HIV antibodies were negative and CMV blood titres were elevated. His acute liver injury was attributed to CMV hepatitis. He completed 6 weeks of anti-viral treatment with ganciclovir. A repeat endoscopy 2 months later showed healing duodenal ulcer with no fistula present. Blood CMV level was negative at the time of completion of anti-viral treatment. He was seen later in the immunology clinic to evaluate why he had such a severe infection from CMV. His labs were significant for only mildly reduced B lymphocyte count – 47 (normal 100-700) with slightly lower immunoglobulin G level 748 (normal 762-1488) and immunoglobulin M level 25 (normal 38-328). Rest of the labs were unremarkable including a complete blood picture, lymphocyte subsets and lymphocyte proliferation studies. It was felt that his CMV infection was isolated and because he had no recurrent infections it was decided by the patient and the immunologist to forego any further investigations of immune deficiency. DISCUSSION: In clinical practice, it is important to exclude CMV infection as a cause of intestinal ulcers even in immune competent patients. Especially if they are accompanied by an enteric fistula. Treatment of the CMV enteric fistula involves both anti-viral therapy and surgical closure of the fistula. Rarely such as in our patient, healing of the fistula can take place without any invasive procedures.