Cytomegalovirus-Induced Gastrointestinal Bleeding and Pancreatitis Complicating Severe Covid-19 Pneumonia: A Paradigmatic Case

Abstract

COVID-19 is a new pandemic disease whose pathophysiology and clinical description are still not completely defined. Besides respiratory symptoms and fever, gastrointestinal (GI) symptoms (including especially anorexia, diarrhea, and abdominal pain) represent the most frequent clinical manifestations. Emerging data point out that severe SARS-CoV-2 infection causes an immune dysregulation, which in turn may favor other infections. Here we describe a patient with severe COVID-19 pneumonia who developed in the resolving phase abdominal pain associated with cytomegalovirus (CMV)-induced duodenitis with bleeding and pancreatitis. A high level of suspicion toward multiple infections, including CMV, should be maintained in COVID-19 patients with heterogeneous clinical manifestations.

Keywords: Cytomegalovirus; SARS-CaV-2.

Figure 1

CT imaging. a) High resolution CT scan of the chest, showing extensive areas of ground-glass opacity, with strands of consolidation and left pleural effusion. b) Coronal arterial phase CT image shows areas of reduced parenchymal perfusion (arrow) and large peripancreatic collections (arrowhead).

Figure 2

a) Upper endoscopy showing multiple large and confluent ulcers in the first and second portions of the duodenum with initial re-epithelialization and an ischemic-like pattern. b) Duodenal ulcer biopsy H&E staining. c) High power view of the area highlighted in «a» H&E: large basophilic CMV inclusions within endothelial cells in the granulation tissue (arrows). d) High power view Immunohistochemistry showing CMV-positive cells.