Curious Case Of Cmv Gastritis In Hiv/Aids Patient

INTRODUCTION: Cytomegalovirus (CMV) is related to herpes virus family and 50%-89% of adults in the United States have been previously infected. Reactivated CMV can affect immunocompromised adults with involvement of gastrointestinal tract mainly esophagus, stomach or colon. We present an interesting case of advanced CMV gastritis. CASE DESCRIPTION/METHODS: 45 year-old Hispanic female with no past medical history presented to the emergency department with complaints of non-radiating right upper quadrant and epigastric pain with intermittent nausea and vomiting along with multiple episodes of foul smelling diarrhea and fevers for four days. Abdomen was tender to palpation in epigastric region without guarding or rebound tenderness, murphy’s sign was negative with positive bowel sounds. Labs showed normal electrolytes and hepatic function panel, Lipase 154 U/L and Amylase was 51 U/L. Abdominal ultrasound revealed cholelithiais with 1.2 cm calculus at the neck of the gallbladder without intrahepatic biliary duct or common bile duct dilation. CT abdomen was suggestive of mild acute pancreatitis and thickening of stomach suggestive of gastritis. Figure 1 Patient developed acute hypoxemic respiratory failure requiring intubation for rest of the hospital course. She was tested positive for HIV/AIDS with a CD4 count of 42 and bronchial lavage was negative for Pneumocystis Jirovecii infection. Hospital course was further complicated by large volume melena necessitating upper endoscopy which suggested extensive ulceration with a large cratered non-bleeding ulcer in the esophago-gastric junction. Figure 2 Multiple biopsies of gastric tissue samples reported severe active inflammation with intraepithelial nuclear and cytoplasmic eosinophilic inclusions consistent with Cytomegalovirus (CMV) infection and coinfection with Helicobacter Pylori and Epstein Barr virus was ruled out. Figure 3. Serum CMV-PCR was > 2 million IU/mL and patient succumbed to her illness despite therapy with Ganciclovir. DISCUSSION: CMV Gastritis and CMV Colitis are the GI manifestation of the CMV infection but very few studies have reported their incidence. The patient was confirmed to have HIV/AIDS during the hospital course and CMV Gastritis was diagnosed with immunohistochemistry of endoscopically obtained biopsy samples. This case adds to the literature about CMV Gastritis in an immunosuppressed individual and should serve as a good teaching and learning case for aspiring gastroenterologists.Figure 1Figure 2Figure 3