Abstract
Background/Aim: The mortality rate for alimentary tract hemorrhage remains high due to a variety of contributing factors. In this report, we present a case of post-severe trauma patient with life-threatening gastrointestinal bleeding caused by cytomegalovirus (CMV)-induced damage to the terminal ileum. Case Report: A 76-year-old female with a history of hypertension and gastrointestinal bleeding developed CMV ileitis post-severe trauma. Despite negative CMV IgM antibodies, PCR testing confirmed CMV infection in the biopsy tissue. Histopathological examination revealed viral inclusion bodies, with immunohistochemistry confirming CMV presence. Results: Intravenous ganciclovir effectively managed symptoms and halted bleeding. CMV ileitis, typically seen in immunocompromised states, may occur sporadically in immunocompetent individuals, including post-orthopedic surgery patients. The exact mechanism remains unclear, possibly related to surgical stress. Diagnosis relies on histopathology and immunohistochemistry. Conclusion: Early recognition and treatment are vital for optimal outcomes, emphasizing the need for awareness among orthopedic surgeons regarding CMV as a potential cause of postoperative complications.
It is well known that the mortality rate of alimentary tract hemorrhage remains high due to multifactorial causes. The primary reasons include gastroduodenal ulcers, varices, gastritis, and stress ulcers, among others (1). For patients, the causes of gastrointestinal bleeding are more complex; therefore, opportunistic infections (OIs) should be given special consideration (2). The typical clinical manifestations of cytomegalovirus (CMV)-related gastrointestinal disease include colitis, esophagitis, and gastritis, which rarely lead to severe bleeding (3). Herein, we present a case of a post-severe trauma patient with life-threatening gastrointestinal bleeding caused by CMV-induced damage to the terminal ileum. This study was approved by the Institutional Review Board (IRB) of Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, and complied with guidelines (IRB No. B202415066, approved on April 12, 2024). Written informed consent has been obtained from the patient to publish this paper.
Case Report
A 76-year-old female, with a medical history encompassing hypertension, paroxysmal atrial fibrillation, and recurrent gastrointestinal bleeding, sustained fractures in her right proximal humerus and right distal femur following a fall, necessitating concurrent open reduction and internal fixation with a locking plate over both sites. Tarry stool, suggestive of suspected gastrointestinal bleeding, was identified three days post-surgery. Upon reviewing her medical records, it was noted that the patient experienced her initial episode of tarry stool attributed to a gastric ulcer in 2018. Between 2018 and 2021, the patient underwent upper gastrointestinal endoscopies five times due to epigastric pain and tarry stool, as well as two colonoscopies due to bloody stool. Diagnoses during this period included gastric ulcer, colonic ulcer, and hemorrhoids. Notably, there have been no documented instances of further gastrointestinal bleeding since 2021, according to the medical records of the patient. Subsequent colonoscopy unveiled multiple centrally depressed ulcerative lesions in the terminal ileum, displaying vessel exposure indicative of CMV ileitis, as highlighted by the arrow in Figure 1. Although serological studies demonstrated the absence of cytomegalovirus IgM antibodies, polymerase chain reaction (PCR) testing on biopsy tissue obtained during the colonoscopy yielded a positive result. Histopathological analysis of the terminal ileum disclosed hypercellular regions beneath erosive mucosa, characterized by the presence of lymphocytes, plasma cells, and enlarged nuclei with eosinophilic material – consistent with viral inclusion. Immunohistochemistry confirmed positive staining for cytomegalovirus in the affected mesenchymal cells, as denoted by the arrow in Figure 2. The administration of intravenous ganciclovir proved effective in ameliorating the patient’s condition and arresting gastrointestinal bleeding.
Multiple centrally depressed ulcerative lesions are present over the terminal ileum (arrow) (A-C).
(A) The section shows lymphoplasmacytic aggregation in the lamina propria of the erosive mucosa region, causing a focus of hypercellular area (arrow) (100×, H&E stain). (B) The high magnification of the specimen reveals aggregated lymphocytes, plasma cells, and polymorphonuclear cells, as well as some mesenchymal cells with enlarged nuclei and eosinophilic, increased-sized nucleoli (400× H&E stain). (C) The immunohistochemical study of cytomegalovirus reveals positive staining in the cytoplasm of the affected cells, indicating cells affected by cytomegalovirus (arrow) (400× immunohistochemical stain of cytomegalovirus).
Discussion
CMV ileitis is an infrequent yet potentially severe condition characterized by inflammation and ulceration of the terminal ileum, arising from CMV infection. While CMV infections typically affect immunocompromised individuals such as those with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) or recipients of solid organ transplantation (4), it may sporadically manifest in immunocompetent patients (5), including those who have undergone orthopedic surgery. Additionally, CMV infections have been found in lymphoma patients treated with Bendamustine and anti-CD20 antibodies (6). The precise mechanism linking CMV ileitis to the postoperative state remains unclear, but physiological stress induced by surgery may heighten susceptibility. Hospital-related factors, such as exposure to fluids, may also contribute to infection transmission, encompassing sexual exposure (via vaginal fluid), close interpersonal contact within families or daycare settings (involving the upper respiratory tract and urine), as well as exposure to blood. Histopathological analysis of tissue samples obtained through endoscopic biopsy or surgical procedures, coupled with immunohistochemical staining for CMV, stands as the most specific diagnostic approach (7). Regrettably, diagnosing gastrointestinal CMV disease can be challenging, particularly in immunocompetent patients where suspicion may be diminished. Regarding CMV duodenitis, there exists a notable potential for mortality (8). In terms of treatment, intravenous ganciclovir continues to be the preferred first-line therapy. Furthermore, novel oral anticoagulants (NOACs), such as rivaroxaban, appear to be safe and may offer a promising alternative with favorable outcomes for patients with CMV infection (9). Early diagnosis and appropriate treatment are crucial for optimizing patient outcomes. CMV ileitis carries a substantial risk of being life-threatening. We encountered several limitations in this case, we regret not conducting CMV IgG and HIV antigen testing. Subsequent diagnostic endeavors should meticulously address these concerns.
Conclusion
We encountered a case involving a post-severe trauma patient who presented with life-threatening gastrointestinal bleeding caused by CMV-induced damage to the terminal ileum. Although intravenous ganciclovir effectively treated the patient, testing for CMV IgG and HIV antigens will be considered in similar future cases. Lastly, orthopedic surgeons should be cognizant that postoperative gastrointestinal bleeding may also stem from CMV infection.
Footnotes
Authors’ Contributions
Conceptualization, Y.-Y.T., J.-W.L. and C.-C.W.; investigation, Y.-Y.T., J.-W.L. and C.-C.W.; writing—original draft preparation, Y.-Y.T., J.-W.L. and C.-C.W.; writing—review and editing, Y.-Y.T., J.-W.L. and C.-C.W.; visualization, C.-C.W.; supervision, Y.-Y.C. All Authors have read and agreed to the published version of the manuscript.
Conflicts of Interest
The Authors declare no conflicts of interest.
- Received May 23, 2024.
- Revision received June 17, 2024.
- Accepted June 28, 2024.
- Copyright © 2024 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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