University of Louisville School of Medicine Louisville, KY, United States
Zainab Farooqui, DO1, Mohamed Eisa, MD2, Dipendra Parajuli, MD1 1University of Louisville School of Medicine, Louisville, KY; 2University of Louisville, Louisville, KY
Introduction: Bone marrow transplant (BMT) is critical in the management of many blood disorders, however an important complication of this is graft-versus-host disease (GVHD), which occurs when donor immune cells attack host tissue. The GI tract is one of the most common areas affected by GVHD; studies have reported GI involvement in 27% of GVHD patients. However, GI symptoms in this population should also prompt additional exploration of other infections that affect immunocompromised patients. This case report shows an unconventional presentation of CMV infection in the setting of multisystem refractory GVHD (rGVHD).
Case Description/Methods: A 73-year-old male with a history of acute monocytic leukemia who underwent BMT in 2013 complicated by rGVHD with GI, pulmonary, and cutaneous involvement on prednisone, cyclosporine and Ruxolitinib. He presented with iron deficiency anemia, hematochezia, and diarrhea. He underwent upper endoscopy and colonoscopy which showed diffuse erosions and erythema of the esophageal mucosa, edema and erythema of the stomach, and patchy heaped-up margins and ulcerations in the transverse colon (Figure 1). Biopsies were positive for Cytomegalovirus (CMV), and subsequently he was started on Gancyclovir.
Discussion: Assessing GI symptoms in patients with a history of GVHD can be challenging as this population is severely immunosuppressed, widening the differential diagnoses. The choice of treatment for GVHD depends on the organs involved, thus prompt diagnosis should be made when there are GI symptoms. On the other hand, CMV disease of the GI tract occurs in 10% of hematopoietic cell transplant patients and causes increased mortality of up to 80%, and multiple studies have shown that GVHD and its treatment put patients at risk for CMV replication. In our case with the history of multisystem rGVHD, there was initial concern for this being the source of his current GI symptoms and endoscopic abnormalities. However, biopsy results confirmed that his GVHD was well-controlled with his current treatment regimen and CMV infection was the culprit. In addition to evaluating the effects of GI involvement in GVHD, providers should remain cognizant of other opportunistic infections in this patients’ population.
Figure: (A) Esophageal mucosa with diffuse erosions and erythema (B) Stomach body with edema and erythema (C) Transverse colon with patchy heaped-up margins and ulcerations
Zainab Farooqui indicated no relevant financial relationships.
Mohamed Eisa indicated no relevant financial relationships.
Dipendra Parajuli indicated no relevant financial relationships.
Zainab Farooqui, DO1, Mohamed Eisa, MD2, Dipendra Parajuli, MD1. P0358 - Cytomegalovirus Esophagitis in a Patient With Refractory Chronic Graft-versus-Host-Disease After Allogenic Bone Marrow Transplantation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.