Ileal Perforation Caused by Cytomegalovirus Infection in a Critically Ill Adult

Abstract

Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract is common and is most often seen in patients with acquired immunodeficiency syndrome (AIDS), inflammatory bowel disease, or those receiving immunosuppressive therapy. CMV infection of the small bowel accounts for only 4.3% of all CMV infections of the GI tract. Isolated cases of small bowel perforation due to CMV have been reported in AIDS patients, and all but one patient has died. This article reports the first case of an ileal perforation due to transfusion-associated CMV infection in a critically-injured non-AIDS patient. Immediate surgical resection and antiviral therapy led to complete recovery. The development of abdominal pain, fever, watery diarrhea, and GI bleeding in a critically ill patient should prompt the clinician to consider the diagnosis of CMV enteritis. If standard stool pathogens and Clostridium difficile toxin studies are nondiagnostic, endoscopic evaluation and CMV serology should be obtained. If CMV infection is confirmed, ganciclovir therapy should be initiated without delay. If bowel perforation occurs. prompt surgical resection is indicated. A heightened level of suspicion for CMV infection in multiply injured trauma victims and other critically ill patients, with earlier recognition of potential small bowel involvement, can hopefully decrease the incidence of bowel perforation, which is usually a fatal event.

Severe Cryptogenic Multifocal Ulcerous Stenosing Enteritis. A Report of Three Cases and Review of the Literature

“…In differential diagnosis of CMUSE, first of all Crohn's disease (9,15), NSAIDs-induced enteropathy (9,35), tuberculosis and other infections of the small bowel (8,9,20), Behcet disease (19,21,24) and malignancies must be excluded. It is a well-known fact, that the majority of extranodal malignant lymphoma involves the gastrointestinal tract.…”

Cytomegalovirus Enteritis in an Immunocompetent Host

“…After the diagnosis of CMV infection, no antiviral drugs were administered to our patient on account of their possible severe side effects (bone marrow suppression, seizures and nephrotoxicity), and of the fact that in most cases CMV enterocolitis resolved spontaneously [8,17,18]. In conclusion, CMV enterocolitis is not frequent in immunocompetent patients.…”

“…The characteristic histological findings of CMV enteritis are cytomegalic inclusion bodies in the endothelial cells of the capillaries [17]. These lesions cause alterations of the intestinal microcirculation, vasculitis and ischemia, and consequently necrosis and perforation [17,18].…”

Cytomegalovirus enteritis mimicking Crohn’s disease in a lupus nephritis patient: A case report

“…Colitis is the most common manifestation of gastrointestinal CMV and can occur either alone or with other systemic involvement. CMV infection of the small bowel, though reported, is distinctly rare, especially in apparently immunocompetent hosts, and only involves 4.3% of CMV infections of the GI tract [3,10] . CMV enteritis presents most commonly with fever, abdominal pain, diarrhea, or hemorrhage.…”

“…Mesenchymal cells are infected most frequently (97%) followed by endothelial cells (35%), smooth muscle cells (6%) and epithelial cells (3%). Mucosal ulcers are seen in more than half the cases [10,11] . CMV ileitis in lupus patients is rare, but has been reported to cause ileal perforation [12] .…”