Synchronous HSV Esophagitis and CMV Colitis in Multiple Myeloma Presenting with Massive GI Bleed

Abstract

Purpose: Opportunistic viral infections like cytomegalovirus and herpes simplex virus constitute a signifi cant component of morbidity in immunocompromised patients. CMV reactivation has a high incidence in patients who undergo autologous bone marrow transplantation for multiple myeloma. Likewise, HSV manifestations including disseminated HSV are observed in HIV and other immunocompromised patients. Here, we report a case of newly diagnosed multiple myeloma presenting with GI bleeding, who was found to have HSV ulcerative esophagitis and CMV ulcerative colitis. An 84-year-old female presented to our facility with a complaint of increasing thoracic spine pain. MRI of spine revealed that she had multiple levels of signal change. Serum electrophoresis showed a spike in IgG, consistent with multiple myeloma. On the following day, she developed acute cord compression at T5, leading to lower extremity weakness and urinary incontinence. Methylprednisone was started, and a ten-day course of radiation was initiated. During the course of hospitalization, she developed odynophagia and massive hematochezia, requiring four packed RBC transfusion to maintain hemoglobin above 10 mg/dl. Esophagogastroduodenoscopy revealed three mid esophageal ulcers and one ulcer at the gastroesophageal junction. Biopsies were obtained from both sites. Distal esophageal biopsy revealed erosive esophagitis with characteristic multinucleated giant cells and immunostains positive for HSV, while mid esophageal ulcers demonstrated inflamed muscularis mucosa with immune stains positive for CMV. Subsequently, colonoscopy was performed and severe ulceration was noted at the splenic flexure, which was suspicious for ischemic colitis. However, biopsies showed acute colitis with fibrinopurulent exudates and viral cytopathic changes consistent with cytomegalovirus, which were confirmed by immunostains. The patient was started on a 14-day course of acyclovir and ganciclovir for HSV and CMV, respectively. Her hematochezia and odynophagia got completely resolved. To the best of our knowledge, this is the first reported case of multiple myeloma having coexistence of HSV and CMV viruses in esophageal ulcers with massive hematochezia due to CMV colitis. Biopsies from multiple sites of ulceration proved to be a pivotal factor in the diagnosis and treatment of our patient.