S1752 Infiltration of the Biliary Tract With Cytomegalovirus

Abstract

Introduction: Cytomegalovirus (CMV) is known to affect immunosuppressed patients. CMV causes infections in post-transplant and HIV/AIDS patients but also those with advanced age or hematologic malignancies. This case presents CMV infiltration of the biliary tract in an elderly patient with 2 hematologic malignancies. Case Description/Methods: A 74-year-old male with tobacco use and chronic alcohol abuse was undergoing evaluation for anemia and thrombocytopenia. EGD and colonoscopy were unremarkable. Bone marrow biopsy revealed myelodysplastic syndrome (MDS) and B cell lymphoma. He subsequently developed jaundice. Labs revealed a total bilirubin of 10.4, ALP 1077, AST 107 and ALT 131. Viral hepatitis panel and HIV were negative. MRCP showed a dilated CBD and a filling defect within the CHD extending to the left hepatic duct with contour irregularity and narrowing in the left hepatic duct giving a beaded appearance. ERCP demonstrated a dilated CBD and CHD in addition to mild left and right hepatic duct dilatation with no definitive strictures or filling defects. A plastic bile duct stent was placed due to poor drainage of contrast. His LFTs continued to remain elevated. Liver biopsy revealed moderate cholestasis, sinusoidal dilatation, mild portal inflammation, biliary metaplasia, and stage 2 fibrosis. Repeat MRCP showed worsening intrahepatic and extrahepatic biliary dilatation with no further filling defect. ERCP with cholangioscopy was then performed. Bile duct mucosa had diffuse superficial granular like appearance in the common duct and main hepatic branches, which did not resemble typical previous biliary stent inflammatory changes. Biopsies of the bile duct were obtained. A fully covered metal stent was placed for further biliary drainage due to persistent poor contrast drainage. Bile duct pathology showed chronic active inflammation with CMV viral inclusions in the hepatic hilum and left hepatic takeoff. CMV PCR from the biliary specimen was positive. Blood CMV IgG was positive. Blood CMV PCR and CMV IgM were negative. His liver enzymes showed improvement after a fully covered stent was placed. He was started on a 2 week course of valganciclovir, with serial blood CMV PCR monitoring while on Rituximab for his B cell lymphoma. Discussion: This patient’s immunosuppression secondary to MDS, B cell lymphoma and advanced age increased his risk of a CMV infection with bile duct involvement. Cholangioscopy can aid in viewing subtle bile duct irregularities with biopsies to assess for CMV involvement.