S2005 Deep Esophageal Ulcers Due to Cytomegalovirus Infection Mimicking Pseudodiverticula in a Patient With Acquired Immunodeficiency Syndrome

Abstract

INTRODUCTION: Cytomegalovirus (CMV) is a common opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS), in whom it has a propensity to cause deep mucosal ulcers in the gastrointestinal tract. Esophageal diverticula are very rare, occurring in < 1% of the general population. A novel case is reported of CMV in the esophagus presenting as esophageal bleeding in an AIDS patient from deep apparent esophageal pseudodiverticula. CASE DESCRIPTION/METHODS: A 44-year-old-male with AIDS for 20 years secondary to intravenous drug abuse, who was only intermittently compliant with antiretroviral therapy, presented with chronic dysphagia, and acute melena and four episodes of hematemesis. Vital signs on admission revealed blood pressure = 162/105 mmHg, pulse = 99 beats/min, respiratory rate = 20 breaths/min and temperature = 36.9 °C. Physical examination revealed cachexia (BMI = 15.78 kg/m2), oral thrush, and a nontender abdomen. Laboratory values included hemoglobin of 6.5 g/dL (normal: 13.5–17 g/dL), without leukocytosis or electrolyte abnormalities. After transfusing 2 units of packed erythrocytes and administering intravenous pantoprazole, a nasogastric (NG) tube was inserted which revealed coffee-ground gastric contents. Esophagogastroduodenoscopy (EGD) demonstrated scattered-cheesy-white-esophageal-exudate highly consistent with candidiasis (Figure-1), esophageal mucosal erosions oozing blood, and four-profound-diverticular-like-esophageal-ulcers (maximal-diameter = 12 mm, depth = 15 mm; Figure-2). Polymerase chain reaction and viral culture of esophageal biopsies revealed CMV. Candida albicans was demonstrated histologically by biopsy (Figure-3). NG tube was carefully removed. Urgent barium swallow and esophagram revealed deep irregular esophageal ulcers without perforation. Hematemesis and dysphagia were attributed to CMV esophagitis and candidiasis esophagitis, respectively. The patient was treated for two weeks with valganciclovir and micafungin for CMV and candidiasis, respectively. The hemoglobin stabilized and the dysphagia resolved. DISCUSSION: A novel case is reported of CMV-induced profound ulcers in an AIDS patient presenting as bleeding esophageal pseudodiverticula. This diagnosis should be considered in the differential diagnosis in immunocompromised patients presenting with hematemesis. In this patient the EGD was diagnostic and showed apparent esophageal pseudodiverticula from the CMV.Figure 1.: Tightly adherent cheesy white to tan mucosal exudate throughout esophagus representing Candida albicans.Figure 2.: Deep esophageal ulcers with maximal diameter = 12mm, depth = 15mm representing cytomegalovirus.Figure 3.: Periodic acid-schiff (PAS) stain of Candida albicans demonstrating elongating hyphae and spherical yeast forms.