Introduction Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract commonly involves the esophagus, Stomach and colon. It frequently affects immune-compromised patients with Human immune deficiency (HIV), malignancy, organ transplant recipients, those on immunosuppressive medications or long standing steroid therapy. The most common symptoms include nausea, vomiting, dysphagia, odynophagia, abdominal pain, tenesmus and hematochezia. The endoscopic findings of CMV infection are variable from simple erosion, ulceration to pseudo-tumor formation. We present a rare case of CMV gastritis in an asymptomatic patient with history of Granulomatosis with Polyangiitis on immunosuppressant.
Case presentation A 62-year-old Hispanic female with past medical history of Granulomatosis with Polyangiitis, hypertension and End Stage Renal Disease on hemodialysis, was evaluated for chronic anemia. Review of symptoms was negative for diarrhea, nausea, vomiting, abdominal pain, melena or hematochezia. Her medications included Furosemide, Amlodipine, Metoprolol, Prednisone and Cyclophosphamide. Physical exam was remarkable for pallor, normal oropharynx and negative for lymphadenopathy. Abdomen was soft, non-tender, non-distended, with normal bowel sounds. Rectal exam revealed external hemorrhoids, guaiac positive brown stools.
Pertinent laboratory data included Hemoglobin/ Hematocrit (7.9 g/dL/23.5%), Mean Corpuscular Volume of 102fL, and Serum Albumin 3.1 gm/dL. Iron studies showed normal Iron-76 mcg/dL with low total iron binding capacity (TIBC)-195. Colonoscopy was significant only for diverticulosis. Esophagogastroduodenoscopy (EGD) revealed multiple erosions in the gastric antrum along with small non-bleeding clean based ulcer (Forrest class III). Biopsy of the gastric antrum showed intra-nuclear inclusions bodies (“owl eye”) with positive immune staining for CMV antigen pathognomonic for CMV gastritis. Patient received intravenous Ganciclovir treatment for one week followed by one week of oral ValGanciclovir.
Discussion There have been reported cases of symptomatic CMV gastritis. However, CMV gastritis in our case patient was asymptomatic. CMV infection can involve any part of the gastrointestinal tract with symptoms usually include nausea, vomiting, dysphagia, odynophagia, abdominal pain, tenesmus and hematochezia (1). It frequently affects immune-compromised patients with Human Immunodeficiency Virus, malignancy, organ transplant recipients, those on immunosuppressive medications or long standing steroid therapy but can affect immunocompetent individuals as well. CMV infection of the gastrointestinal tract commonly involves the esophagus, stomach and colon. The endoscopic findings of CMV infection are variable from simple erosion, ulceration to pseudo-tumor formation. In patients with persistent immune deficiency such as granulomatosis with polyangiitis, endoscopic evaluation is a reasonable approach to prevent potential serious complications such as gastrointestinal hemorrhage, progressive intestinal disease and death.
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