S2842 A Story of Small Bowel Ulcers and Multi-Organ Failure

Abstract

INTRODUCTION: In tissue-invasive CMV, the most predominant GI presentation is CMV colitis. The incidence and clinical presentation of CMV enteritis however is much more rare and less understood. CASE DESCRIPTION/METHODS: A 70-year old male with hypertension and atrial flutter presented to the hospital with fevers, dyspnea and weight loss. He was found to have a pulmonary embolism and was discharged on Xarelto. He was then readmitted for abdominal pain. CT abdomen showed severe wall thickening in the distal duodenum and first portion of the jejunum. He developed abdominal distension, bright red blood per rectum and a diffuse rash, which was attributed to vasculitis. Repeat CT abdomen showed severe thickening of the mid jejunum, ileum and descending colitis. EGD showed multiple large non-bleeding duodenal and proximal jejunal ulcers with skip areas showing normal appearing small bowel. Similar findings were seen in the terminal ileum. Patchy mild inflammation was found in the ascending colon. Biopsies were consistent with CMV enteritis. He developed an acute abdomen. In the OR he was found to have a perforated ileum. Given poor prognosis post-operatively, he was transitioned to comfort care. DISCUSSION: For tissue invasive CMV, CMV colitis is the most predominant GI presentation while small bowel involvement is the most rare. Patients with CMV enteritis can present with anorexia, abdominal pain, obstruction, perforation or hemorrhage. Diagnosis is made with tissue biopsy as serum CMV PCR has a low positive predictive value for tissue-invasive disease. CMV infects the vascular endothelial cells, leading to ischemia and ulceration. Biopsies should therefore target the ulcer base to include these cells. Endoscopically, CMV infection may appear as inflammation, shallow or deep ulcers or pseudo-tumor formation. Histology shows diffuse ulcerations with necrosis and Cowdry inclusion bodies. Evaluation for immunosuppressive conditions is important as tissue-invasive CMV is almost exclusively in immunocompromised patients. There is a lack of data on treatment but extrapolation from CMV colitis suggests the use of Ganciclovir. When clinical suspicion is high, PCR testing for quicker results in order to start therapy is recommended. Given the devastating consequences of a delay in diagnosis, it is important to keep CMV enteritis in the differential despite its rarity.Figure 1.: CT Angiography of small intestine with wall thickening.Figure 2.: Endoscopy showing ulceration in the small bowel.Figure 3.: Pathology A: small bowel mucosa with ulcer; B: rare CMV inclusion identified in granulation tissue on the H&E stain; C: CMV positive cells highlighted by a CMV immunostain.