A Rare Case of Cytomegalovirus (CMV) Gastritis, Duodenitis, and Retinitis with Gastrointestinal Bleeding Due to Non-cirrhotic Portal Hypertension Complicating Treatment for Lymphoma: Case Report and Review of Literature

Abstract

Introduction: CMV infections and sinusoidal obstruction syndrome (SOS) are both rare complications that can be associated with chemotherapy treatment. CMV infections, while rare in general, are most often associated with hematologic malignancies. SOS occurs as a result of damage to the hepatic sinusoidal endothelial cells and can have the same sequelae as other liver diseases. We present an interesting case of a patient with lymphoma who developed CMV gastritis and SOS, likely as a result of chemotherapy treatment. Case: A 74-year-old man with a past medical history of stage IV mantle cell lymphoma presented to our emergency room with nausea, epigastric pain, bloating and weight loss. His lymphoma had been previously treated with six cycles of bendamustine and rituximab. Upper endoscopy demonstrated a normal upper esophagus and a lower esophagus with diffusely nodular and erythematous mucosa as well as areas of ulceration. The stomach demonstrated diffusely erythematous and edematous gastric folds. The duodenum appeared normal. Biopsies of the stomach and duodenum demonstrated CMV infection. The patient was treated with valgancyclovir for a 21-day course. The patient developed acute onset of central vision loss with a vitreous fluid sample positive for CMV on PCR. He was restarted on valgancyclovir. He subsequently presented to the hospital with multiple episodes of upper gastrointestinal bleeding. Endoscopy demonstrated active oozing from GOV1 gastric varices. After further evaluation, the patient was found to have non-cirrhotic portal hypertension, requiring transjugular intrahepatic portosystemic shunt placement to control variceal hemorrhage. The most likely cause of his portal hypertension was SOS related to chemotherapy for mantle cell lymphoma. He has been stable without further bleeding but with episodes of encephalopathy managed successfully with lactulose and rifaximin.Figure 1Figure 2Figure 3Discussion: The case demonstrates complications that can occur with chemotherapy. Both CMV infections and SOS are rare complications of treatment with immunosuppressive medications, but can lead to very serious complications if not discovered and managed early. It is essential to bear in mind the variety of iatrogenic issues associated with chemotherapy and immunosuppression, including infection and hepatic injury, which may be severe and require intensive intervention.