S1387 A Case of Rapidly Progressive Disseminated Cytomegalovirus Causing Acute Pancreatitis in the Setting of Acquired Immune Deficiency Syndrome

Abstract

INTRODUCTION: Widespread dissemination of opportunistic infections is increasingly recognized in AIDS, many times found on autopsy when causing gastrointestinal pathology. However, premortem acute pancreatitis caused by opportunistic infections is rarely diagnosed. CMW is a double stranded DNA with a reported prevalence of 60-100% (1). In an immunocompromised individual, disseminated CMV can cause a variety of pathology. We will discuss a middle aged female who was found to have acute pancreatitis in the setting of CMV viremia causing rapid deterioration. CASE DESCRIPTION/METHODS: 45 year old El Salvadorian female presented with abdominal pain, nausea, vomiting and diarrhea. Lipase on admission was 154 U/L. CT showed evidence of acute pancreatitis, gastritis and colitis. Denied alcohol use and triglyceride levels were normal. An MRCP did not show any obstruction of the bile duct. Patient became febrile and HIV test was positive with high viral load and CD4 count less than 20. Denies being sexually active but was raped while crossing the border two years prior. Course complicated by septic shock requiring intubation and vasopressors secondary to PCP pneumonia. Patient suffered from a GI bleed and EGD brushings showed candida throughout the upper GI tract. Biopsies of the gastric body, antrum and duodenum came back positive for CMV. CMV DNA was >20000 IU/ml and started on Ganciclovir. Repeat CT still showed evidence of acute pancreatitis. Patient went into renal failure requiring CVVH and ultimately the patient passed due to complications of septic shock. DISCUSSION: CMV in immunocompromised patients is common, but CMV pancreatitis is rare. A retrospective study analyzed autopsy CMV in AIDS patients and 81/164 had CMV infection, but organ failure was in 17 patients. Another study conducted autopsies on patients with CMV infections, and 10% were found to pancreatic involvement. The exact mechanism is still not well understood, but one proposed mechanism suggests endothelial cells release trypsin which results in pancreatic inflammation and autodigestion of cellular membranes. In this case, the patient met diagnostic criteria for pancreatitis by sharp epigastric abdominal pain with loss of appetite and CT findings of acute pancreatitis. Lipase levels are not correlated to the severity of disease, however in the three documented cases of CMV pancreatitis lipase was >1000 U/L. CMV should be on differential when a patient with AIDS presents with acute pancreatitis.