S4243 Unmasking the Silent Culprit: Cytomegalovirus Gastritis Striking an Immunocompetent Host!

Introduction: Cytomegalovirus (CMV) gastrointestinal (GI) disease is rarely seen in immunocompetent (IC) hosts but when present it can cause significant morbidity and mortality. It typically affects the colon and rectum in patients with inflammatory bowel disease (IBD) on biologics, however, it seldomly affects the upper GI tract. Evaluation of anemic patients with upper GI symptoms in IC individuals has broad differentials such as infectious, medication-related, malabsorption, malignancy, and sometimes IBD. Here we present a case of CMV gastritis in an IC patient presenting with dyspepsia, anemia and weight loss. Case Description/Methods: A 66-year-old Asian man with a history of hypertension, diabetes mellitus was seen in GI clinic for evaluation of new-onset anemia. The patient reported dyspepsia, 10 lb weight loss, and intermittent black stools. He reported history of smoking, but denied NSAIDS (except ASA 81 mg)/ alcohol / prior malignancy / immunocompromised state or blood thinner use. He had a normal esophagogastroduodenoscopy (EGD) and colonoscopy 2 years ago. Initial labs were significant for Hb 10.2g/dL and MCV 78fL. Given the risk factors for Helicobacter pylori infection and age, he underwent EGD which showed mild gastric erythema and gastric antral nodular mucosal erosion (Figure 1). Biopsy showed multiple fragments of gastric mucosal epithelial cells with viral cytopathic effects positive for CMV by immunohistochemistry and negative for H. pylori or malignancy. The patient was treated with omeprazole 40 mg by mouth daily and oral valganciclovir 900 mg PO BID x 3 weeks. Follow-up repeat EGD at 3 months, and CBC is still pending. Discussion: Studies have shown that the average age of IC patients with CMV gastroenteritis is around 65 years and predominantly man, which fits our patient profile. Endoscopic findings of discrete ulcers or diffuse erythema are usually associated with or without exudate. Interestingly, our patient lacked serological positivity, supporting the hypothesis that CMV gastroenterocolitis in IC patients may be a result of local rather than systemic reactivation for which tissue CMV PCR is suggested as a more useful tool for diagnosis.IC patients with CMV gastritis are prone to resolve unaidedly, needing to assess disease burden before medication. Given the age-related increase in seroprevalence of CMV infection even in IC patients, healthcare providers must maintain a high index of suspicion while evaluating the patients with new-onset dyspepsia, anemia, and negative typical workups.Figure 1.: Endoscopic finding of single 12 mm mucosal nodular erosion in gastric antrum and mild gastric erythema.

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