Eisenhower Medical Center Rancho Mirage, CA, United States
Youssef Ghobrial, MD1, Sina Mirbagheri, MD1, Joline De Castro, MD2, Ammar Qureshi, MD2, Mehrdad Asgeri, MD, FACG1 1Eisenhower Medical Center, Rancho Mirage, CA; 2Eisenhower Health, Rancho Mirage, CA
Introduction: Cytomegalovirus (CMV) infection is uncommon and is classically seen in immunocompromised patients. COVID-19 is a novel virus that has been observed to cause extensive immunosuppression in the host. We present a unique case of biopsy-proven CMV-related rectal ulcer in a patient suffering from COVID-19 pneumonia.
Case Description/Methods: The patient is a 72-year-old female with a history of COVID-19 pneumonia who presented to the hospital complaining of lower abdominal pain and multiple episodes of hematochezia for 4 days. 3 weeks prior to presentation she was hospitalized for COVID-19 pneumonia where she was treated with decadron, antibiotics, and O2 supplementation. She does not drink alcohol or use NSAIDs. She was noted to be hypotensive and tachycardic with a hemoglobin of 6.5. 4 units of packed red blood cells were ordered and she was transferred to the ICU for further management. Gastroenterology was consulted who then proceeded with EGD and colonoscopy. EGD showed a superficial 1.5 x 0.3 mm non-bleeding ulcer in the gastric body and mild gastritis. Colonoscopy showed a solitary circular 3 x 3 cm rectal ulcer and sigmoid diverticulosis. Complete hemostasis was achieved and biopsy results from the rectal ulcer were positive for CMV. Plasma CMV DNA by PCR was also positive. Infectious disease was consulted and the patient was started on Valganciclovir 450 mg daily for 5 weeks. The patient was followed in the outpatient setting and recovered after treatment.
Discussion: Cytomegalovirus is a DNA virus that commonly infects humans but is typically asymptomatic in immunocompetent hosts. CMV reactivation in patients suffering from COVID-19 pneumonia is not well documented in the literature given COVID-19 is a novel virus. Dexamethasone is a corticosteroid that has been studied in a large randomized control trial which reduced 28-day mortality and decreased the likelihood of requiring mechanical ventilation in patients with moderate to severe COVID-19 pneumonia. Consequently, high doses of dexamethasone for prolonged periods of time can result in significant immunosuppression allowing for opportunistic infections or reactivation of viruses. While diarrhea may be a common symptom in early COVID-19 disease, this case illustrates that there may be a role for colonoscopy to exclude concurrent infection in these patients who present with hematochezia.
