title: Cytomegalovirus duodenitis associated with life-threatening duodenal hemorrhage in an immunocompetent patient: A case report.
abstract: BACKGROUND
  Cytomegalovirus (CMV) is known to be opportunistic in immunocompromised patients. However, there have been emerging cases of severe CMV infections found in immunocompetent patients. Gastrointestinal (GI) CMV disease is the most common manifestation affecting immunocompetent patients, with duodenal involvement being exceedingly rare. Presented is a case of an immunocompetent patient with life-threatening bleeding caused by CMV duodenitis, requiring surgical intervention.
  
  
  METHODS
  A 60-year-old male with history of disseminated Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and aortic valve infective endocarditis, presented with life-threatening upper GI hemorrhage. Endoscopy revealed ulcerations, with associated generalized mucosal bleeding in the duodenum. After repeated endoscopic therapies and failed interventional-radiology arterial embolization, the patient required a duodenectomy and associated total pancreatectomy, to control the duodenal hemorrhage. Pathologic review of the surgical specimen demonstrated CMV duodenitis. Systemic ganciclovir was utilized postoperatively.
  
  
  CONCLUSIONS
  GI CMV infections should be on the differential diagnosis of immunocompetent patients presenting with uncontrollable GI bleeding, especially in critically ill patients due to transiently suppressed immunity. Endoscopic and histopathological examinations are often required for diagnosis. Ganciclovir is first-line treatment. Surgical intervention may be considered if there is recurrent bleeding and CMV duodenitis is suspected because of high potential for bleeding-associated mortality.
  
  
  CONCLUSIONS
  Presented is a rare case of life-threatening GI hemorrhage caused by CMV duodenitis in an immunocompetent patient. The patient failed endoscopic and interventional-radiology treatment options, and ultimately stabilized after surgical intervention.
authors.affiliation: Department of General Surgery, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada. Electronic address: lucy.shenn@gmail.com.
authors.forename: Lucy
authors.initials: L
authors.lastname: Shen
authors.affiliation: Department of General Surgery, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Youssef
authors.affiliation: Department of Pathology, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada.
authors.forename: Suzan
authors.initials: S
authors.lastname: Abu-Abed
authors.affiliation: Department of Infectious Diseases, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada.
authors.forename: Sangita K
authors.initials: SK
authors.lastname: Malhotra
authors.affiliation: Department of Gastroenterology, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Atkinson
authors.affiliation: Department of General Surgery, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada.
authors.forename: Elena
authors.initials: E
authors.lastname: Vikis
authors.affiliation: Department of General Surgery, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada.
authors.forename: George
authors.initials: G
authors.lastname: Melich
authors.affiliation: Department of General Surgery, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada.
authors.forename: Shawn
authors.initials: S
authors.lastname: MacKenzie
keywords: Cytomegalovirus; Duodenitis; Duodenum; Enteritis; Gastrointestinal bleed; Immunocompetent