Ulcerative Jejunitis Secondary to Cytomegalovirus Infection

Abstract

Purpose: Introduction: Cytomegalovirus (CMV) infections of the GI tract have been described in both immunocompromised and immunocompetent hosts; however, the most common sites of infection are the colon, stomach, terminal ileum and esophagus. We present a case of ulcerative jejunitis due to CMV infection found on push enteroscopy. Case Report: A 56-year-old female with stage IV colon cancer transferred to our hospital after a negative one month work-up for melena and diarrhea. She was originally diagnosed with Stage IV colon cancer two years prior to presentation and had a partial colectomy, splenectomy and cholecystectomy. She received a course of chemotherapy that was discontinued due to decline in functional status. Four months prior to her presentation at our hospital, she was diagnosed with a recurrence at the umbilicus. Chemotherapy was restarted and three months later, she presented with diarrhea, fatigue, leukocytosis, fevers and melenic stools. She had an EGD which showed mild esophagitis with normal pathology, normal colonoscopy and repeatedly negative stool cultures. Due to the severity of her bleeding, an urgent exploratory laparotomy was performed that only showed distended but otherwise unremarkable appearing bowel. Due to the persistence of her symptoms, a push enteroscopy was performed, revealing extensive diffuse jejunal inflammation with shallow ulcerations. Pathology revealed non-specific findings without granuloma or dysplasia in the jejunum; however, immunohistochemical stains revealed positive CMV staining with negative adenovirus and HSV staining. Capsule endoscopy was performed and revealed ulcerated mucosa in numerous segments starting in the proximal jejunum. During her initial work-up, her CMV IgG was positive and her IgM was negative. Her serum CMV PCR was initially undetectable (<250 copies/mL;); however, repeat CMV PCR several days into her hospital course was 2109 copies/mL. She was started on gancyclovir IV and eventually transitioned to valganciclovir PO indefinitely with resolution of her symptoms. Conclusion: There are very few reports of CMV infection that is primarily isolated in the jejunum. However, the potential implications of morbidity and mortality related to the diagnosis are critical and warrants suspicion in any patient with obscure GI bleeding, especially the immunocompromised. This case highlights the importance of endoscopic and histologic evaluation for accurate diagnosis and treatment despite negative CMV serologic studies.