S2872 A Case of CMV Enteritis Resulting in Severe Obscure GI Bleeding

Abstract

INTRODUCTION: Small bowel (SB) bleeding accounts for less than 5% of gastrointestinal (GI) bleeds, in non-IBD patients, with an even smaller portion originating from the jejunum [1]. Locating SB bleeds poses great challenges, frequently resulting in delay in diagnosis. Although SB arteriovenous malformations (AVMs) are most common, other rare etiologies such as infectious enteritis should be considered. CASE DESCRIPTION/METHODS: A 62 year old male was diagnosed with T-cell lymphoma with EBV positivity and placed on high-dose steroids for one month. Staging CT chest, abdomen, and pelvis incidentally revealed intraperitoneal free air with concerns for a gastric wall neoplasm. EGD revealed a 4cm, deep, non-bleeding, non-perforated ulcer in the gastric body (Image 1). Two weeks after, he had painless melanotic stools, requiring multiple transfusions. Emergent arteriography of the celiac and mesenteric arteries did not identify a source of bleeding. Repeat CT imaging was negative for worsening free air. His course continued to worsen, requiring high-dose vasopressors and continued transfusions. Emergent EGD and colonoscopy were performed. EGD revealed a known, non-bleeding gastric ulcer. Colonoscopy showed bright red blood to the cecum with scattered, non-bleeding, ischemic-appearing ulcers (Image 2). Repeat celiac angiogram was performed two more times, eventually revealing active bleeding from small jejunal artery branches which were embolized. Due to concern for ongoing bleeding, surgical resection of the distal jejunum and proximal ileum was performed. Gross pathology demonstrated extensive ulcerations, with biopsies negative for malignancy (Image 3). Serum testing for Cytomegalovirus (CMV) was positive for strongly elevated quantitative levels and the patient was started on Valganciclovir. DISCUSSION: Delays in diagnosing SB bleeds are not uncommon and can frequently be fatal. Our case presents a complex diagnostic scenario where bleeding was presumed to be from the known gastric lesion, but complicated by inability to perform EGD safely with pneumoperitoneum. Ultimately, the patient’s immunocompromised state and steroids predisposed him to opportunistic infections such as CMV, resulting in bleeding ulcers in the jejunum and ileum. Upon literature review, CMV enteritis is exceedingly rare and accounts for under 5% of all CMV infections in the GI tract [2]. Though rare, CMV enteritis has been reported to cause massive hemorrhage requiring emergent surgery and is often associated with high mortality.Figure 1.: 4cm non-bleeding ulcer in the gastric body seen on the initial EGD.Figure 2.: Scattered ischemic-appearing colonic ulcers.Figure 3.: Gross specimen of resected and ulcerated jejunum.