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A 76-year-old woman with a history of myelogenous leukaemia was admitted with haematochesia fever (38.3°C) and slight abdominal pain. Haemoglobin was 8 g/l, WBC 8.2×109/l, platelets were 55×109/l and partial thromboplastin time was 23 s. Gastroscopy was normal, colonoscopy did not reveal the source of haemorrhage, but a CT-angiography indicated the source at the ileo-caecal region.
Non-surgical therapy including 8 units of blood and 8 units of fresh frozen plasma was performed in 3 days, but haemorrhage continued, (HB 6 g/l).
A right hemicolectomy was performed including en-block resection of 40 cm of the terminal ileum. Intraluminal absence of blood and focal thickening around the ulcers guided the extent of resection. The presence of multiple ulcers was confirmed before closing the abdomen, figures 1 and 2. Histology revealed no malignant infiltration, but inflammation with intracellular inclusion bodies and serology consisting of IgG anti-cytomegalovirus (CMV), and IgM anti-CMV indicated the CMV as the aetiology of the ulcers.
Segment of the resected terminal ileum with three distinct ulcers. Each ulcer is indicated by four white arrows. The crater of each ulcer is surrounded by an opaque oedematous ridge and the convergence of circular plicae.
Segment of the resected caecum and ascending colon showing two distinct ulcers of colitis. Each ulcer is indicated by four white arrows. The crater of each ulcer is surrounded by an opaque oedematous ridge and the convergence of the intestinal plicae. The multiple mucosal red spots represent inflammatory focuses and mucosal erosions. The red arrows indicate the opened ilecaecal valve.
Postoperatively, the haemorrhage did not recur but the patient developed a low-output entero-cutaneous fistula (3rd week). She initially showed improvement by total parenteral nutrition, antibiotics and ganciclovir. Nevertheless, the patient's haematological status remained poor and she died 70 days after surgery in sepsis due to pneumonia.
CMV1 2 is a herpes virus with a propensity to affect immunocompromised patients as transplant recipients, patients with AIDS, haematological malignancies and inflammatory bowel disease. Pneumonia, gastrointestinal inflammation, ulcerations and haemorrhage, hepatitis and encephalitis are the most common complications with high mortality. Antiviral therapy (ganciclovir, valganciclovir) should be considered.3
Learning points
The multiplicity and wide spread of ileal and colonic ulcers make the assessment of the extent of surgical resection difficult.
Surgery should be reserved for life-threatening complications as haemorrhage and perforation.
Long-term prognosis is largely determined by the underlying haematologic disease.
Footnotes
Competing interests None.
Patient consent Obtained.