Infectious esophagitis is a nuisance complication in the occurrence of systemic or esophageal immunodeficiency. Cytomegalovirus (CMV) is one of the most common opportunistic pathogens that cause infectious esophagitis, especially in post-transplant patients due to its potential to spread hemodynamically and increase viral load under immunosuppression. Odynophagia with or without dysphagia is the most common presentation and high index of suspicion must be attained in an immunocompromised patients with this complaint. To our best knowledge, limited data exists about infectious esophagitis presenting as a mechanical gastrointestinal emergency. We report a case of an immunocompromised patient with ulcerative CMV induced esophagitis which resulted in an impending near food bolus impaction.
The patient is a 63-year-old Caucasian male with End Stage Renal Disease who had a living unrelated donor renal transplant six months prior to his presentation with severe dysphagia and odynophagia. His immunosuppressive regimen consisted mycophenolate mofetil, tacrolimus and prednisone. His dysphagia and odynophagia were mostly to solids over the past month for which he was empirically treated with fluconazole for presumed candida esophagitis with no improvement in his symptoms. An esophagogastroduodenoscopy (EGD) was performed which revealed multiple, clean based, deeply cratered, esophageal ulcers in a circumferential manner involving the mid and distal esophagus (Figure 1). The ulcers had adherent food debris that prevented the passage of the endoscope and occupied the entirety of the esophageal lumen, that were removed with aggressive irrigation (Figure 2). Histopathology showed non-specific necro-inflammatory debris with no evidence of CMV or Herpes simplex (HSV). An inner lip mucosal ulcer was then identified and biopsied showing evidence of inclusion bodies, with confirmed CMV.
This report contributes to a better understanding of atypical presentations of infectious esophagitis in immunocompromised patients. Despite the fact that is a common disease, it is often missed and complications like fistulas, strictures and/or esophageal perforation may result due to delays in treatment. Because gastrointestinal disease may be patchy, multiple biopsies may be needed to confirm the diagnosis of esophagitis, as in our case. A simple negative pathology report does not exclude the diagnosis and if high clinical suspicion, findings should not be attributed to other etiologies.