S2852 Tissue Invasive Cytomegalovirus Enteritis With Gastric Outlet Obstruction in an Immunocompetent Patient

Abstract

INTRODUCTION: Cytomegalovirus (CMV) usually causes asymptomatic or mononucleosis-like syndrome in immunocompetent individuals. We present a case of severe tissue invasive gastrointestinal CMV in an immunocompetent individual complicated by gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 72-year-old man with a history of hypertension presented with vomiting, postprandial abdominal pain, and hematochezia for one week. He had also lost 40lbs in three months. Physical examination was normal except for epigastric tenderness. The previous colonoscopy done 5 years ago was normal. No personal or family history of inflammatory bowel disease, gastrointestinal malignancy, or lymphoma. He had never had immunosuppressive therapy, organ transplantation, or any other biological agent. Initial blood work revealed Hemoglobin 10.9 g/dl, AST 64 IU/l, ALT 83 IU/l, and ALP 350 IU/l. His HIV and Tuberculosis screening were negative. Ultrasound and CT scan of the abdomen and pelvis were normal except for increased gallbladder wall thickness (3mm). An Esophagogastroduodenoscopy (EGD) revealed esophagitis, pyloric channel ulcer, and duodenal ulcer. Colonoscopy revealed an ulcer at the ileocecal valve. The biopsy of all the ulcers revealed ulcerated mucosa, architectural distortion, and reactive epithelial atypia suspicious of CMV infection which was later confirmed by immunohistochemical staining (IHC) [Figure 1]. Quantitative CMV DNA PCR analysis showed levels of 1739 IU/ml. He was started on intravenous ganciclovir while inpatient and sent home on oral valganciclovir for 21 days. His symptoms improved significantly after treatment. CMV DNA levels decreased to 1230 IU/ml post-treatment. The patient returned with symptoms of gastric outlet obstruction a few months later which were getting worse. His barium X-ray revealed a delayed gastric emptying time with pyloric stenosis and partial malrotation of the small bowel [Figure 2]. A repeat EGD revealed pyloric stenosis with an inner diameter of 11 mm, which was dilated endoscopically. The biopsy taken from an antral ulcer was negative for CMV on IHC staining. There were no other signs of prior CMV infection on the EGD. DISCUSSION: The gastric outlet obstruction in the patient is likely a long term sequela of CMV. Due to the undertreatment and delay in diagnosis, CMV infections can lead to long term and potentially life-threatening complications. Therefore, gastrointestinal CMV should be considered in immunocompetent patients and aggressively treated.Figure 1.: Medium power (100×) Immunohistochemical staining for CMV with hematoxylin counter-stain. A representative high power view demonstrating strong focal CMV immunoreactivity.Figure 2.: Barium Xray reveals pyloric stenosis (black arrow) and malrotation with the first loop of jejunum to the right.