CMV Induced Terminal Ileum Stricture Presenting as a High Grade Small Bowel Obstruction

Introduction: Cytomegalovirus (CMV) colitis is typically found in patients that are immunocompromised and is rarely found in immunocompetent patients. CMV ileitis has been primarily described in AIDS patients and is found in 4% of CMV cases affecting the GI tract. In this case, we present an immunocompetent patient who presented with a high grade small bowel obstruction (SBO) that was secondary to CMV ileocolitis causing a terminal ileum stricture. Case Description: A 60-year-old immunocompetent, HIV-negative black male presented with small bowel obstruction. CT scan of the abdomen showed circumferential wall thickening of the terminal ileum (TI). Colonoscopy was unrevealing due to incomplete bowel prep. He was deemed a poor candidate for surgery given severe cardiomyopathy. Outpatient colonoscopy was planned for after completion of two weeks of prednisone for presumed Crohn’s disease. The patient had persistent abdominal pain requiring readmission. Colonoscopy showed ulcerations and erosions in the TI and cecum with a TI stricture that could not be transversed. Biopsies were taken and showed crypt distortion and ulceration; immunohistochemical staining was positive for Cytomegalovirus (CMV). Patient underwent bowel resection, and gross specimen further confirmed viral cytopathic change with multiple superficial ulcerations and vasculature containing endothelial cells with prominent viral inclusions positive for CMV. Discussion: CMV ileitis is rare in immunocompetent patients. A systematic review of immunocompetent patients with CMV in any system in 2008 described 60 patients with CMV colitis. There is only one other case report of a patient with a CMV –induced colonic stricture presenting as an acute intestinal obstruction in an immunocompetent adult. This is the only case of CMV terminal ileocolitis with primary ileal involvement that caused acute intestinal obstruction in an immunocompetent adult

A catastrophic series of events

Introduction: Catastrophic Anti-phospholipid Syndrome (CAPS) is a rare life-threatening condition that occurs i

Running and rapping our way to wellness: internal medicine residency approach to preventing burnout

Background: Physician burnout has led to increased cardiovascular disease, shorter life expectancy, problematic alcohol use, depression, and suicide. A recent meta-analysis on burnout and patient experience highlighted the strong association between physician wellness and the quality of patient care. Unfortunately, burnout in internal medicine ranks among the highest of all specialties, with rates up to 76%. Purpose: To facilitate resident mental and physical well-being through initiatives focused on supportive colleague relationships and exercise. Methods: We implemented two related interventions. 1) RAPS (Resident Advisor for Peer Success) is a structured peer advisor program for incoming interns to jump-start a “connection” with their continuity clinic team shortly after match day. This early and sustained contact provides interns with an immediate resource for questions/support and ongoing connections with senior residents and a faculty advisor. 2) Fit4Life intervention continued to build/ support colleague relationships through personal fitness. Wellness challenges between trainee years were held to promote physical health per American Heart Association (AHA) exercise guidelines. Three measures — a Fit4Life survey, semi-structured interviews with interns, and Mayo Well-Being Index (MWBI) — were used to evaluate process and outcomes. Results: Fit4Life pre-, during, and postchallenge data showed that less than 20% of internal medicine residents met AHA guidelines: 150 minutes/week of aerobic physical activity. Challenge period results showed a modest but not significant increase in exercise. Average completion rate was 83% of internal medicine residents. Exercise, per AHA recommendations, was paired \u3e50% of time with another activity (eg, watch/listen to television, movies, music, podcasts; connecting with family/friends). RAP intern interviews (13 of 13 [100%]) revealed that 85% were supportive of RAPS and 100% met weekly with RAPS team member(s) at continuity clinic. MWBI scores throughout intervention were well below instruments established at risk level for burnout (5.0), with below burnout scores ranging from 3.1 preintervention (February 2018) to 2.3 postintervention (December 2018). Conclusion: The results of our well-being interventions focused on supportive colleague relationships through RAPS and exercise reveal high participation rates and support but no significant impact on physical or mental health as measured by Fit4Life and MWBI