A 80-year-old female with a past medical history of diabetes mellitus, hypertension and coronary artery disease status post stenting 4 years ago presented with coffee ground emesis, epigastric pain, dysphagia and melena. On examination, her vital signs showed a heart rate of 92 beats/minute and blood pressure of 89/55 mm Hg. Her abdomen was soft without any rebound or tenderness. The rest of the physical examination was normal except for bilateral pitting pedal edema. Laboratory examination showed a hemoglobin and hematocrit of 9.7/30.8 which was decreased from a baseline of 11.4/36. She was resuscitated with IV fluid and started on a pantoprazole drip. An upper gastrointestinal (UGI) endoscopy showed severe duodenitis and Los Angeles (LA) classification grade D esophagitis without evidence of bleeding. Biopsy showed markedly active inflammation with ulceration and H. pylori testing was negative. Despite being on pantoprazole drip and later started on sucralfate, the patient continued to have epigastric pain, dysphagia and intermittent hematemesis. A repeat UGI endoscopy 3 weeks later again showed LA grade D esophagitis and duodenitis. Biopsy at this time showed severe duodenitis and esophagitis with presence of large intranuclear and small intracytoplasmic inclusions which was positive for cytomegalovirus (CMV) with immunohistochemical stain. Serum CMV viral load by PCR was 6300 IU/mL. The patient was started on intravenous ganciclovir with improvement of symptoms and resolution of hematemesis.
Discussion:
Cytomegalovirus gastrointestinal infection is common in immunocompromised patient, especially those with HIV/AIDS when CD4 count falls below 50 cells/uL. CMV infection in immunocompetent patients is usually asymptomatic and commonly present as mononucleosis syndrome. CMV gastrointestinal infection is very rare infection in immunocompetent patient with only few case reported in the literature. Esophagitis is the second most common gastrointestinal manifestation after colitis due to CMV infection. Advancing age is a potential risk factor for CMV esophagitis in immunocompetent hosts, likely because of the associated decline in cellular and humoral immunity. Most patients present with dysphagia, odynophagia, epigastric pain, hematemesis and melena. Diagnosis is made by the visualization of characteristic lesions on endoscopy, which shows shallow ulcers or erosion. Definitive diagnosis is by histopathology which shows the presence of intranuclear and intracytoplasmic inclusions. Ganciclovir is the preferred treatment. Foscarnet is an alternative in those with a contraindication to ganciclovir or if there is concern for ganciclovir resistance.
Conclusions:
CMV esophagitis is a very rare infection in immunocompetent patient. Advancing age causing a decreased cellular and humoral immunity might be a significant risk factor for CMV infection in an immunocompetent patient.