C0328 - CMV-Induced Small Bowel Bleeding Complicating Severe COVID-19 Respiratory Failure

Monday, October 24, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Wesley A. Robertson, MD, MPH, MPA

University of Arizona College of Medicine
Phoenix, AZ

Wesley A. Robertson, MD, MPH, MPA¹, Natasha Narang, DO¹, Louis NovoaTakara, MD², Richard Shaughnessy, DO²
¹University of Arizona College of Medicine, Phoenix, AZ; ²Banner University Medical Center, Phoenix, AZ

Introduction: Since the onset of the COVID-19 pandemic, reports of associated gastrointestinal (GI) symptoms have been widespread. Of these symptoms, upper GI bleeding is relatively uncommon, and typically associated with peptic ulcer disease and anticoagulation use. Few recent reports have described cytomegalovirus (CMV) co-infection with COVID-19 thus far in the literature. Though CMV gastroenteritis is common amongst immunocompromised hosts, CMV infection in previously immunocompetent hosts is rare.

Case Description/Methods: A 59-year-old previously immunocompetent male with history of chronic obstructive pulmonary disease and chronic kidney disease was admitted with severe COVID-19 pneumonia. He received standard COVID therapy with tocilizumab and dexamethasone.
On hospital day 27, he developed decreased stool output, followed by bloody nasogastric tube output, melena, and acute anemia, requiring urgent transfusion and gastroenterology consultation. Upper endoscopy revealed atrophic gastritis and multiple nonbleeding duodenal ulcers with nodular duodenal mucosa; biopsies revealed cytomegalovirus. Colonoscopy showed deep ulcerations throughout the entire terminal ileum, colon, and rectum, also due to CMV. He was subsequently started on intravenous ganciclovir with clinical improvement, absence of further GI bleeding and gradual decline of CMV viral load (table 1).

Discussion: It has been previously described that COVID-19 treatment with tocilizumab can cause reactivation of CMV leading to colitis. However, COVID-19-associated CMV duodenitis is exceedingly rare, with limited cases reported thus far. In one report, a 73-year-old man with severe COVID-19 respiratory failure developed abdominal pain in the recovery phase and was noted to have CMV-induced duodenitis and pancreatitis. However, this patient had recent diagnosis of primary cutaneous large B-cell lymphoma and was thus immunosuppressed.¹
This is the first case describing COVID-19-associated CMV duodenitis in a previously immunocompetent host. Moreover, this is only the second reported case of CMV duodenitis in any COVID-19 patient. We suggest any critically ill patient with COVID-19 and gastrointestinal bleeding should be assessed for infectious etiologies such as CMV.

Reference: Marchi G, Vianello A, Crisafulli E, et al. Cytomegalovirus-Induced Gastrointestinal Bleeding and Pancreatitis Complicating Severe Covid-19 Pneumonia: A Paradigmatic Case. Mediterr J Hematol Infect Dis. 2020;12(1):e2020060. Published 2020 Sep 1. doi:10.4084/MJHID.2020.060

Figure: Figure 1. Upper endoscopy findings of diffusely nodular mucosa with many non-bleeding superficial ulcers in the second and third portions of the duodenum (Fig 1a). Hematoxylin and eosin stain (x40 magnification) showing CMV inclusion bodies (Fig 1b) and immunohistochemistry stain showing CMV immunoreactivity (Fig 1c).

Treatment Day #	CMV Titer (IU/mL)
Day 1	367,000
Day 5	61,200
Day 7	55,800
Day 14	6,800
Day 17	1,300
Day 25	600
Day 42	197
Day 48	< 96

Table: Decline of cytomegalovirus viral load (based on serum PCR) after treatment started with intravenous ganciclovir on ‘Day 0’.

Disclosures:

Wesley Robertson indicated no relevant financial relationships.

Natasha Narang indicated no relevant financial relationships.

Louis NovoaTakara indicated no relevant financial relationships.

Richard Shaughnessy indicated no relevant financial relationships.

Wesley A. Robertson, MD, MPH, MPA¹, Natasha Narang, DO¹, Louis NovoaTakara, MD², Richard Shaughnessy, DO². C0328 - CMV-Induced Small Bowel Bleeding Complicating Severe COVID-19 Respiratory Failure, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.