Obscure Overt GI Bleed: A Case of CMV Ileitis in an Immunocompetent Patient

Abstract

Obscure GI bleeding is an unidentified source of GI bleeding after a negative EGD, colonoscopy and barium small bowel follow-through. Up to 75% of these patients have a bleeding source in the small intestine. We present a patient with recurrent severe hematochezia, with negative upper endoscopy, colonoscopy and visceral angiogram, who was found to have bleeding Ileal ulcers on video capsule endoscopy with retrograde balloon enteroscopy showing bleeding vessels and pathology consistent with Cytomegalovirus. A 52-year-old male with history of Granulomatosis with Polyangiitis (GPA) and end stage renal disease (ESRD) presented with five episodes of Hematochezia. He was off immunosuppression for more than four years. Colonoscopy showed large amount of blood in the colon with moderate diverticuli but no active bleeding. A subsequent EGD was negative. Over the next 2 days, patient had multiple episodes of hematochezia. He underwent a tagged RBC scan, which showed blood in the terminal ileum but the visceral angiogram was negative for active bleeding. A video capsule endoscopy showed ulcerations in proximal to mid ileum. Retrograde balloon push enteroscopy showed ulcers at 135 cm from entry site in Ileum and two bleeding vessels were clipped. Results of ulcer biopsy showed intracellular inclusion bodies suggestive of Cytomegalovirus (CMV), which was confirmed with Immunostains and patient was started on oral Valganciclovir. CMV is known to cause severe infections in immunocompromised patients, but is usually mild and self-limiting in immunocompentent patients. CMV can involve any segment of the gastrointestinal tract, but most commonly involves the colon and small bowel involvement is rare. Most common presenting symptoms include fever, abdominal pain, diarrhea and bleeding per rectum, however massive transfusion dependent GI bleeding, intestinal perforation and intestinal obstruction have been reported. Diagnosis of CMV enteritis is usually made by histopathology which shows intracellular granules combined with Immunostains positive for CMV. Viral cultures and PCR are also helpful. Differential diagnosis of CMV enteritis involves colitis caused by C. difficile, ischemia, colonic malignancies and inflammatory bowel diseases. Treatment involves administration of IV Ganciclovir or oral Valganciclovir. It has been suggested that immunocompetent patients usually tend to recover spontaneously and do not need treatment. However it is hard to define the criteria of immunocompetency. In our case the patient was off immunosuppressant's for over four years, although it can be argued that presence of comorbidities like GPA and ESRD creates a state of relative immunosuppression. Our case highlights the diagnostic dilemma in patients with obscure GI bleed and additionally, is a rare presentation of CMV ileitis in a immunocompetent patient.Figure 1Figure 2Figure 3