A 62-year-old man presented to the emergency department with 5 weeks of worsening lower abdominal pain associated with watery diarrhoea, vomiting and 10% loss of body weight. He had recently experienced night blindness.
There was no history of foreign travel. His past medical history included hypertension, sickle cell trait and type 2 diabetes well controlled on metformin. He had not been prescribed any recent steroids and denied significant alcohol intake.
On examination, he had a tachycardia at 110 bpm and was afebrile and normotensive. He was malnourished with pedal pitting oedema extending to both knees. His abdomen was soft but distended and diffusely tender.
Blood tests showed a serum albumin of 12 g/L. Stool samples were negative. HIV testing was negative, and immunoglobulin levels were normal.
CT of the abdomen showed thickened, hyperenhancing jejunal loops with diffuse mesenteric inflammatory fat stranding and enlarged mesenteric lymph nodes. Colonoscopy was unremarkable.
Enteroscopy showed granular oedematous mucosa and extensive, deep ulcerations. Jejunal biopsies were obtained. Microscopy samples were negative for tuberculosis (TB) culture.
Histology revealed inflamed and ulcerated small bowel mucosa with plump endothelial cells with the appearance below. There were no granulomata (figures 1 and 2).
Question What is the differential diagnosis?
- small bowel disease
- enteric infections
- antiviral therapy
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The diagnosis is cytomegalovirus (CMV) infection of the jejunum.
The plump endothelial cells contained viral inclusions and showed positive staining with monoclonal antibody against CMV (figure 3).
Blood analysis showed significant viral replication (327 000 copies/mL) CMV IgG but not IgM was detected. Serum vitamin A, magnesium, manganese, selenium and copper were all low.
The patient made a full recovery after 21 days of intravenous ganciclovir. Parenteral nutrition, electrolyte replacement and intramuscular vitamin A were required to treat malnutrition. Vitamin A does not reverse night blindness but prevents further deterioration.
CMV infection is common worldwide. It spreads via most bodily fluids.1 Severe infection occurs in immunocompromised patients. Patients with HIV who have a CD4 count <502 cells/mm3 and those receiving T-cell depleting drugs are at particular risk.3
In immunocompetent individuals, CMV infection is usually mild or asymptomatic and rarely affects the gut.4 Karigane et al reported 32 cases of CMV colitis or enteritis. Thirty recovered completely and two died from secondary bacterial infections. There were no deaths directly attributable to CMV infection.5
CMV enteritis presenting with intestinal failure in an immunocompetent patient has not previously been reported. CMV infection should be considered in patients with intestinal failure. Prompt treatment may prevent life-threatening complications.
Thank you to the gastroenterology department for their support and guidance in writing this case report and to the patient who kindly agreed to share his story for the advancement of human knowledge.
Contributors Conception and design of study: GAS, JC. Acquisition of data: GAS, JC, JO’D. Analysis and/or interpretation of data: GAS, EL. Drafting the manuscript: GAS, JC, BW, JO’D. Revising the manuscript critically for important intellectual content: GAS, BW, JO’D. Approval of the version of the manuscript to be published: GAS, JC, BW, JO’D, EL.
Funding Funding provided by University Hospital Lewisham Gastroenterology Department Research Fund.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; internally peer reviewed.
Collaborators Suzanne Donnelly, David Reffitt, David Dewar.
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