Not Your Typical Case of Hemoptysis: A Rare Presentation of Severe CMV Esophagitis

Abstract

Cytomegalovirus (CMV) infection is rare in immunocompetent individuals but is a major pathogen for immunocompromised patients. The spectrum of disease is broad and includes a range of gastrointestinal diseases. Esophagitis is the second most common gastrointestinal manifestation of CMV infection after colitis. A 40-year-old Chinese woman with end-stage kidney disease on immunosuppression after failed renal transplant was sent from the clinic for urgent initiation of hemodialysis. On initial presentation, she complained of mouth ulcers, which subsequently resolved. During the hospitalization, she developed belching and nausea with food intake, with no dysphagia. She also had multiple bouts of hemoptysis associated with fevers and chills. Tuberculosis was initially suspected, however, a chest x-ray was normal. During one episode of hemoptysis, she developed tachycardia, EKG changes, and an elevated troponin. A computed tomography (CT) angiogram was negative for pulmonary embolism but showed mild esophageal dilatation, wall thickening, and mild pneumomediastinum suggesting possible esophageal perforation. An esophagram was negative for extravasation of contrast but revealed irregular esophageal contour with linear ulcerations. An EGD demonstrated sloughed off severely friable mucosa with spontaneous bleeding, inflammation, and ulcerations throughout the esophagus consistent with severe erosive esophagitis. Given the friability of the esophagus on examination, no biopsies were taken due to the concern for perforation. The patient was started empirically on ganciclovir and intravenous pantoprazole. CMV PCR DNA returned positive and all other serologies were negative. Ganciclovir caused severe leukopenia and was discontinued after seven days of treatment. Subsequently, a repeat EGD was performed and showed a normal esophagus. CMV infection with GI involvement is present in 26% of renal transplant recipients. In our case, biopsies were not performed given concern for perforation; however CMV diagnosis was established based on positive PCR. The most common symptoms of CMV esophagitis are odynophagia, dysphagia, and chest pain. Our patient presented with hemoptysis and esophagitis was incidentally established to be the cause. Given the high prevalence of esophagitis in this population, a high index of suspicion must be maintained even with atypical presentations.FigureFigure