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Editor’s quiz: GI Snapshot

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From question on page 964

Small bowel barium through enema showed a 20 cm stenosis with parietal thickening located in a jejunal loop. Laparotomy showed an infiltrated jejunal loop, which was resected. The rest of the abdominal cavity examination was normal. Macroscopic findings showed jejunal stenosis due to ulcerations of the mucosae, which was thickened, with pseudomembranes.

Pathological findings showed jejunitis with typical intranuclear inclusions indicating a cytomegalovirus (CMV) infection. CMV jejunitis was confirmed by immunohistochemistry in jejunal tissue, which was strongly positive. CMV serological markers showed the presence of IgM and IgG anti-CMV antibodies. No immunosuppressive state was found: no corticosteroid intake; HIV antibodies, p24 antigenaemia, HTLV 1 and 2 antibodies, and Bence-Jones proteinuria were negative; protein immunoelectrophoresis, CD4 and CD8 counts, and thorax and abdominal computerised tomography scan did not show any abnormality. Gastrointestinal CMV infection usually occurs in non-immunocompetent patients and often presents as bloody diarrhoea. To our knowledge, this is the first case localised to the jejunum and presenting as a bowel obstruction in a immunocompetent patient. This case shows that CMV infection may present as a small bowel obstruction in healthy hosts. Therefore, CMV inclusions cells should be examined in mucosal biopsy specimens in patients with small bowel obstruction, to allow for the diagnosis.

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