Cytomegalovirus gastroenteritis can be a life-threatening infection in patients with the acquired immunodeficiency syndrome. Although gastrointestinal ulcerations from cytomegalovirus have been widely reported, our patient is only the second case reported with actual perforations in the small bowel

Fisher, Evelyn J.

Gruenberg, James C.

Houin, Herman P.

Mezger, Eugene

English

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical Journal Volume 35 Number 1 Article 3 3-1987 Multiple Small Bowel Perforations Secondary to Cytomegalovirus in a Patient with Acquired Immunodeficiency Syndrome Herman P. Houin James C. Gruenberg Evelyn J. Fisher Eugene Mezger Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Houin, Herman P.; Gruenberg, James C.; Fisher, Evelyn J.; and Mezger, Eugene (1987) "Multiple Small Bowel Perforations Secondary to Cytomegalovirus in a Patient with Acquired Immunodeficiency Syndrome," Henry Ford Hospital Medical Journal : Vol. 35 : No. 1 , 17-19. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol35/iss1/3 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Multiple Small Bowel Perforations Secondary to Cytomegalovirus in a Patient with Acquired Immunodeficiency Syndrome Herman P. Houin, MD,* James C. Gruenberg, MD,^ Evelyn J. Fisher, MD,* and Eugene Mezger, MD§ Cytomegalovirus gastroenteritis can be a life-threatening infection in patients with the acquired immunodeficiency syndrome. Although gastrointestinal ulcerations from cytomegalovirus have been widely reported, our patient is only the second case reported with actual perforations in the small bowel. (Henry Ford Hosp Med J1987;35.17-9) Cytomegalovims (CMV) is an important source of infectious morbidity and mortality in immunosuppressed patients. CMV has been a recurrent problem in patients with organ trans-plantations (1) or the acquired immunodeficiency syndrome (AIDS) (2), CMV is known to cause ulceration and bleeding in the esophagus, stomach, small bowel, and colon (3-6). A case of small bowel perforation secondary to CMV in an AIDS patient was reporied in 1984 (7), We are reporting the second AIDS case with small bowel perforation caused by CMV, Case Report A 28-year-old homosexual man with a four-year history of lymphadenopathy developed AIDS in December 1982, The diagnosis was based on the presence of Pneumocystis carinii pneumonia and a low T-lymphocyte helper/suppressor cell ratio of 0,23, CMV comple-ment fixation antibody titer was low-normal at 1:8, Several stool exam-inations were negative for bacterial and parasitic pathogens. Urine and blood cultures for CMV were negative. Treatment with sulfamethox-azole-trimethoprim resolved his pneumocystosis, but diarrhea persisted. During the nexl five months the patient continued to have low-grade fevers, progressive weight loss, abdominal pain, and five to seven diar-rheal stools perday. Flexible sigmoidoscopy was normal. In May 1983, CMV retinitis developed, and he went blind in the right eye. On admission in June 1983, our patient was very cachectic, weighing only 118 lbs—a 67 lb weight loss over eight months. His abdomen was markedly distended, tymphanitic, and tender, A trial of cimetidine did not relieve his diarrhea. Stool cultures on one occasion grew Aero-monas hydrophila, but were negative on multiple repeated cultures. On his eighth hospital day, he developed an upper gastrointestinal hemor-rhage which resolved. Endoscopy with biopsies revealed acute gastritis and chronic duodenitis. The patient subsequently developed tachycar-dia, hypotension, and pneumoperitoneum. At exploratory laparotomy, multiple well-circumscribed perforations were present in the ileum and distal jejunum (Figs 1 and 2); the colon was grossly normal. Three feet of ileum and jejunum were resected with construction of a proximal jejunostomy and terminal ileum mucous fistula. Microscopic examina-tion of the surgical specimen showed multiple well-defined lesions of the small bowel with punctate perforations and inclusions of CMV (Fig 3). Postoperafi veiy, he could never be weaned from the ventilator. Bron-choscopy showed CMV, but no Pneumocystis in the lungs. In addition to pulmonary insufficiency, our pafient developed progressive renal and liver failure and died three weeks postoperatively. Necroscopy revealed bilateral pneumonitis, an enlarged congested liver, splenomegaly with infarcts, and renal changes consistent with acute renal failure. Diffuse peritonitis and focal intraabdominal orga-nizing abscesses were present. The distal colon had patchy ulcers with one sealed perforation. The remaining small bowel was grossly normal, Generalized CMV infection was present on microscopic examina-tion, CMV inclusion bodies were found in the larynx, trachea, heart, lungs, entire gastrointestinal tract, pancreas, thyroid, adrenal glands, and paratracheal lymph nodes. The liver was enlarged with chronic congestion and cholestasis with acute centrilobular hemorrhagic necro-sis. The brain had acute anemic infarcts of the right and left gyri along with glial nodules and asti-ocystosis, Alzheimer's type 11, Postmortem viral lung cultures grew CMV. Discussion Although his CMV serological titers were not elevated, this patient suffered from extensive CMV infection including pneu-monitis, retinitis, and complete gastrointestinal tract involve-ment from the esophagus to the rectum with subsequent small bowel perforation. Microscopic examination of the small bowel revealed heavy infiltrate of histiocytes and other mononuclear cells adjacent to the point of perforation. The cells of this infiltrate as well as vas-cular endothelium were enlarged and contained intranuclear and intracytoplasmic inclusions consistent with CMV infection. Submitted for publication: April 26, 1986. Accepted for publication: May 30, 1986. ^Department of General Surgery, Henry Ford Hospital. tFormerly Department of General Surgery, Henry Ford Hospital. Cunrently Department of Surgery, Saginaw Cooperative Hospitals, Inc, Saginaw, Ml. ^Department of Internal Medicine, Division of Infectious Diseases, Henry Ford Hospital. ^Department of ftthology, Division of Microbiology, Henry Ford Hospital. Address correspondence to Dr. Gruenberg, Department of Surgery, Saginaw Cooperative Hospitals, lne, 1000 Houghton Ave, Suite 6000, Saginaw, MI 48602. Henry Ford Hosp Med J—Vol 35, No 1, 1987 CMV Gastroenteritis in AIDS—Houin et al 17 Fig 1—E.xcised segment ofthe small bowel displays multiple areas of focal necrosis and perforations. loss, CMV must be suspected when treating AIDS patients with diarrhea of unknown etiology (8). Prior to the case of terminal ileum perforation in an AIDS patient as described by Frank and Raicht (5), all reported gastrointestinal perforations secondary to CMV had been limited to the large bowel. Clinicians treating AIDS patients should recognize that small bowel perforations may accompany aggressive CMV infections and that serologic tests for CMV are often not helpful. References 1. Marker SC, Howard RJ. Simmons RL, etal. Cytomegalovirus infection: A quantitative prospective study of 320 consecutive renal transplants. Surgery 1981;89:660-71. 2. Reichert CM. O'Leary TJ, Levens DL, SimrellCR, Macher AM, Autopsy pathology in acquired immune deficiency syndrome. Am J Pathol 1983; 112:357-82, 3. Campbell DA, Piercey JRA, Shnitka TK, Goldsand G, Devine RDO, Weinstein WM. Cytomegalovirus-associated gastric ulcer Gastroenterology 1977;72:533-5. 4. Foucar E, Mukai K, Foucar K, Sutherland DER, Va.iBuren CT. Colon ulceration in lethal cytomegalovirus infection. Am J Clin Pathol 1981; 76:788-801, 5. Frank D, Raicht R. Intestinal perforation associated with cytomegalovirus infection in patients with acquired immune deficiency syndrome. Am J Gas-troenterol 1984;79:201-5. 6. Gertler SL, Pressman J, Price P, Brozinsky S, Miyai K. Gastrointestinal cytomegalovirus infection in a homosexual man with .severe acquired immu-nodeficiency syndrome. Gastroenterology 1983;85:1403-6. 7. Horowitz L, Stern JO, Segerra S. Gastrointestinal manifestations of Kaposi's sarcoma and AIDS. In: Friedman-Kien AE, Laubenstein LJ. eds. AIDS. New York: Masson Publishers USA, Inc, 1984:235-9. 8. Knapp AB. Horst DA. Eliopoulos G, et al. Widespread cytomegalovirus ga.stroenterocolitis in a patient with acquired immmunodeficiency syndrome. Gastroenterology 1983 ;85:1399-1402, Fig 2—Closer view ofan area of developing necrosis in the small bowel. The blood vessels were partially or complelely obstmcted as a result of CMV vasculitis, either from enlarged endothelial cells or from thrombosis. In areas ofthe bowel distant from the perforations, the vas-culitis and cellular infiltrate were confined mainly to the mucosal villi, resulting in edema and necrosis of villi. Progres-sion of the vasculitis subsequently to the submucosa and muscularis apparently led to further necrosis and perforation. Although we were unable to definitively correlate gastroin-testinal CMV infection with our patient's diarrhea and weight 18 Henry Ford Hosp Med J—Vol 35, No 1. 1987 CMV Gastroenteritis in AIDS—Houin et al " J i • '* .* h f V. 4' *; r Eig 3—Small bowel mucosa shows loss of epithelium and massive infiltrate of histiocytes. Histiocytes and endothelial cells are enlarged and display intranuclear and intracytoplasmic inclusions (hematoxylin-eosin stain) (X320). Henry Ford Hosp Med J—Vol 35, No 1, 1987 CMV Gastroenteritis in AIDS—Houin et al 19 

Multiple Small Bowel Perforations Secondary to Cytomegalovirus in a Patient with Acquired Immunodeficiency Syndrome

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Multiple Small Bowel Perforations Secondary to Cytomegalovirus in a Patient with Acquired Immunodeficiency Syndrome

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