Cure My Virus: Hematemesis and Melena in a Transplant Recipient

Abstract

The gastrointestinal service was consulted to help care for a hemodynamically unstable 45-year-old man with complaints of hematemesis and hematochezia. His history included congenital heart disease requiring cardiac transplantation at age 20, with ongoing immunosuppressive therapy, currently on azathioprine 25 mg, tacrolimus 1.5 mg, and prednisone 5 mg daily. Other prominent comorbidities included diffuse large B cell lymphoma, diabetes mellitus type II, end-stage renal disease (ESRD) requiring hemodialysis, cardiac conduction abnormalities requiring pacemaker placement, atrial fibrillation, and anticoagulation for an intramural cardiac thrombus; he also suffered from recurrent enteric infections with Clostridioides difficile. His surgical history included duodenal and multiple small bowel resections for ischemic injury due to chronic mesenteric vascular insufficiency. At the time of consultation, he had experienced 10–12 bouts of hematochezia with large amounts of bright red blood. Though he reported chronic diarrhea, he denied any abdominal pain, dyspepsia, or weight loss. A CT scan of his abdomen and pelvis obtained in 2017 revealed severe mucosal thickening of the cecum with proximal distension that had raised concerns about the possible presence of a colon cancer but this was later excluded. He had been admitted 1 month previously to another hospital with similar complaints, had undergone visceral angiography, and had been diagnosed with an abdominal arterial thrombosis. A CT scan of the abdomen and pelvis at this time had revealed a severely abnormal appearance of most of the colon, with marked thickening of the bowel wall suggestive of ischemia, especially in the ascending and transverse colon. Given the patient’s history of vascular insufficiency, there was concern for ischemic colitis, possibly due to a vascular steal syndrome or due to ischemic strictures. His hospitalization had been complicated by the development of several deep venous thromboses (DVTs). On this admission, the patient underwent EGD and colonoscopy for ongoing hematemesis and hematochezia, respectively, with heightened concern for the presence of colonic necrosis. EGD revealed two linear esophageal ulcers with oozing blood and stigmata of recent bleeding; the largest lesion was 3 mm in diameter. Bipolar probe coagulation was used to achieve hemostasis (Fig. 1). The gastric cardia and fundus and duodenum were normal. Colonoscopy revealed moderate segmental mucosal changes characterized by erosions and erythema at the hepatic flexure, in addition to a chronic, benign-appearing stricture (Fig. 2) which, given patient’s history of vascular insufficiency, was thought to be due to ischemic colitis. Biopsy showed granulation tissue with rare endothelial cells showing viral cytopathic effects consistent with cytomegalovirus (CMV) infection. Diagnosed with CMV colitis, he was treated initially with IV ganciclovir, and later changed to oral valganciclovir. Antiviral treatment was followed by complete cessation of his diarrhea; a repeat CT scan showed complete resolution of the previously noted thickening of the wall of the cecum. It was assumed that the colitis had been present for a prolonged period and may at some time have involved the liver or another organ, as treatment of CMV was followed by normalization of a previously elevated serum alkaline phosphatase.