Cytomegalovirus pancreatitis in an immunocompetent patient

Abstract

Cytomegalovirus (CMV) is a double-stranded DNA virus, which infects a large portion of the adult population. In immunocompetent patients, it typically is asymptomatic or manifests as mild and self-limiting flu-like illness symptoms, whereas in immunocompromised patients, CMV can cause significant disease. Herein we report an unusual case of CMV pancreatitis in an immunocompetent 75-year-old female. Patient developed severe significant pancreatic necrosis that failed non-operative management, and ultimately underwent pancreatic necrosectomy. Later on, she developed three spontaneous gastric perforations. The first two perforations were managed operatively, but after the third perforation family decided not to undergo another operation. The CMV pancreatitis diagnosis was based on pancreatic histopathology and confirms by a prompt response to ganciclovir. Patient was promptly started on intravenous (IV) ganciclovir which resulted in clinical recovery and she remained asymptomatic more than one-year post op. This is a rare case of CMV pancreatitis with gastric perforations in an immunocompetent patient. High degree of suspicion and appropriate treatment are important for such clinical scenarios.

Keywords: ALT, alanine transferase; AST, aspartate transferase; BMI, body mass Index; CKD, chronic kidney disease; CMV, cytomegalovirus; CT, computed tomography; Cytomegalovirus; DIC, disseminated intravascular coagulation; EBV, Epstein Barr virus; EGD, esophagogastroduodenoscopy; GI, gastrointestinal; Ganciclovir; Gastric perforation; ICU, intensive care unit; OR, operating room; PCR, polymerase chain reaction; POD, post-operative day; Pancreatic necrosis; Pancreatitis.

Fig. 1

CT scan with IV contrast demonstrating pancreatic necrosis with surrounding inflammation.

Fig. 2

A: Initial CT scan demonstrating gastric perforation in the lesser sac. B: CT scan demonstrating second perforation in greater curvature of stomach.

Fig. 3

Histology slides demonstrating A: necrotic pancreas (black arrow) and cluster of CMV cells (yellow arrow) slides and B: positive immune stain for CMV (black arrow).