S3073 A Rare Cause of Repeat Hemorrhage: When Cytomegalovirus Hides in the Small Bowel

Abstract

Introduction: Cytomegalovirus (CMV) is an opportunistic infection typically seen in immunocompromised patients, like those with Human Immunodeficiency Virus (HIV) or organ and stem cell transplant recipients. CMV infections are exceedingly uncommon in the immunocompetent duodenum. We describe such a case, confirmed with biopsy and complicated by severe repeated gastrointestinal hemorrhage. Case Description/Methods: A 74-year-old male with PMH of diabetes, bladder cancer (status-post resection and ureteral stent placement), presented to the ED with general malaise. Was found to meet sepsis criteria and was anemic with bright red blood on rectal exam. CT abdomen and pelvis revealed multiple pelvic abscesses and free air. Stool testing was positive for C. diff and oral vancomycin and IV zosyn were started. Patient was admitted to telemetry and required 3 separate units pRBC for persistent anemia. CTA abdomen performed on day 3 revealed a duodenal bleed. IR performed an embolization, however, patient remained unstable and required intubation and pressors. Anemia continued to worsen, and patient received an additional 2 units pRBC. GI performed a bedside EGD revealing a large clot and duodenal ulcer. Sepsis continued to worsen, and antibiotics were broadened to meropenem and vancomycin. Anemia continued to worsen, and an additional EGD was performed with source control reported. Patient was extubated, and shortly thereafter, had melena, so a final EGD was performed, identifying friable mucosa and a bleeding duodenal vessel. Hemospray and a clip were deployed to contain bleeding, and the patient received a seventh unit of blood. Biopsied duodenal tissue stain showed CMV (Figure 1A) and histology revealed inclusions (Figure 1B), so ganciclovir was started. Recurrent bleeding subsequently resolved, and patient was discharged to subacute rehabilitation to complete a course of IV ganciclovir. Discussion: Though rare in immunocompetent patients, CMV infections should be considered in severe or persistent gastrointestinal bleeds. CMV duodenitis, while very uncommon, has been documented in case reports and is associated with ischemia and massive hemorrhage. In this case, the patient ultimately required seven units of blood, intubation, and numerous endoscopic procedures as a result of CMV duodenitis. Clinical improvement was seen only once the underlying infection was treated and illustrates the need to consider CMV infection in the differential for recurrent gastrointestinal bleeding.Figure 1.: A: Immunohistochemical stain of tissue from duodenal biopsy identifying CMV. B: Histology of duodenal tissue biopsy under high power showing CMV inclusions.