The splenic abscess was drained percutaneously and grew multiple species consistent with oral flora. Given the unusual location of the ulcer and lack of risk factors, the ulcer was thought to represent either a malignant process or a direct extension of a primary splenic abscess into the stomach. A repeat EGD was undertaken to perform additional biopsies, which were negative for malignancy but revealed CMV gastritis with extensive ulceration (Figure 3). Human immunodeficiency virus (HIV) screening was negative. Surgical management of the ulcer was deferred due to its location near the gastroesophageal junction; the splenic abscess was managed conservatively. The ulcer was endoscopically closed with Ovesco clipping (Ovesco Endoscopy AG, Tübingen, Germany) and overstitching. She was discharged on nasojejunal tube feeds, intravenous antibiotics, and ganciclovir.
Early during the course of her outpatient follow-up, an abdominal CT showed a non-specific para-aortic mass potentially consistent with adenopathy in the setting of ongoing splenic abscess. Despite the multimodal endoscopic closure, the gastric ulcer did not close and led to persistent fluid collection outside of the stomach, which required placement of a percutaneous drain by interventional radiology. Follow-up abdominal CT obtained 6 weeks after the previous showed progression of the para-aortic mass in the setting of resolved abscess. Given the concern for malignancy, a CT-guided biopsy was positive for diffuse large B-cell lymphoma and positron emission tomography-CT showed diffuse abdominal disease (Figure 4). The patient was initiated on chemotherapy with the R-CHOP treatment (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone). Her gastric perforation has fully healed and she is currently in clinical and radiographic remission.
This case represents both a rare location and a rare underlying etiology of gastric perforation. While gastric erosions and ulceration are common, perforations are less common and can occur secondary to peptic ulcer disease, trauma, neoplasms, surgical or endoscopic complications, or infections including CMV. Known complications of CMV infections in the gastric tract include perforation, ulceration, hemorrhagic proctocolitis, and lesions mimicking neoplasia.1 Specifically, CMV enteritis and gastritis in immunocompromised patients has been well described in the literature, and patients with lymphoma are known to be at risk for CMV infection given altered cell-mediated immunity.2,3 CMV-associated perforations are much less frequent but have been seen in patients with malignancy.4–9 However, these cases were reported in East Asian patients who had a known malignant diagnosis and underwent immunosuppressive therapy. Furthermore, not only is this presentation rare, potentially leading to low clinical suspicion of CMV, but the diagnosis of CMV-induced gastric ulceration can be difficult because its presentation can be quite varied on gross endoscopic examination, often requiring pathologic diagnosis.10,11 If evaluation for underlying causes of gastritis or gastric ulcer is unrevealing, it is reasonable to consider further testing for CMV with mucosal biopsies. If CMV infection is found, then clinicians should consider evaluation for potential causes of an immunocompromised state including HIV, history of immunomodulating therapy, and malignancy.
Author contributions: E. Krajicek reviewed the literature, drafted the manuscript, and is the article guarantor. R. Shivashankar and S. Hansel edited the manuscript.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
Received August 11, 2016; Accepted November 14, 2016
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© 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.
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