P0096 - Acute Cytomegalovirus Infection Can Present with Acute Obstructive Cholangitis

Min Win, MD¹, Thin Myat, MD^2
1Valley Digestive & Liver Care Center, Fresno, CA; ²VA Central California Health Care System, Fresno, CA

Introduction: Cytomegalovirus (CMV) infection of a gastrointestinal organ is uncommon in an immunocompetent patient. We present a rare cause of transient biliary obstruction and cholangitis in an immunocompetent patient following active enteritis with ulceration at ampulla by CMV.

Case Description/Methods: 57 year old male with PMH of hypertension, diabetes, hyperlipidemia, acute gangrenous cholecystitis & cholelithiasis required laparoscopic cholecystectomy 2 years ago presented with acute abdomen pain, fever 101F and jaundice. He has no history of smoking, drinking or drug abuse. Physical examination showed jaundice, scleral icterus but no lymphadenopathy or skin lesion. Admission Lab showed WBC of 19.4K with 10% atypical lymphocyte, ALT 74, AST 58, ALKP 787, T.bil 5.2, D.bil 4.0, LDH 247, lipase 910, and triglyceride 151 mg/dl. Heterophile antibody was negative. Infectious hepatitis and autoimmune pancreatic work up were negative. CT abdomen showed moderate intrahepatic biliary dilation and CBD dilation to 10 mm. MRCP showed intrahepatic and CBD dilation and enhancement of distal CBD consistent with early cholangitis. He was started on broad-spectrum antibiotic for cholangitis. ERCP with occlusion cholangiogram showed dilated biliary tree, balloon extraction showed biliary sludge, cytology brushing of distal CBD was unremarkable and ampulla biopsy revealed active enteritis with ulceration and CMV viral inclusion. EUS revealed no mass in pancreas.

Discussion: CMV infection in immunocompetent patient is generally asymptomatic or may present as a Mononucleosis syndrome. Mononucleosis presents with significant protracted fever, absolute lymphocytosis with atypical lymphocyte on peripheral smear. Approximately one-third of patient has maculopapular eruptions, mild anemia, low hepatoglobin, cold agglutinin and negative Heterophile antibody. Disease localized to a single organ such as CMV colitis has been described in an immunocompetent patient but these cases are rare and limited to small series and case report. CMV colitis in these patients can occur in setting of primary infection. Subclinical transaminitis is more common presentation. Majority of immunocompetent patients with CMV recover without intervention in days or weeks. It is difficult to prove whether or not antiviral therapy has significant impact on clinical outcome.


Disclosures:
Min Win indicated no relevant financial relationships.
Thin Myat indicated no relevant financial relationships.


Min Win, MD¹, Thin Myat, MD². P0096 - Acute Cytomegalovirus Infection Can Present with Acute Obstructive Cholangitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.