Prepared by Bernadette M. Wildemore, MD, Chief Resident, and Christopher V. Nguyen, MD, Chief Resident, Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, Pa

A 51-year-old woman with a history of acute myelogenous leukemia treated with bone marrow transplantation presented with persistent, severe epigastric pain. After her transplant, she had received corticosteroids for graft-versus-host disease prophylaxis. Endoscopy revealed a linear ulcer in the duodenal bulb. Histologically, the ulcer showed inflamed mucosa with numerous large intranuclear eosinophilic inclusions in the glandular epithelium (Figure, Panel A) as well as in the surrounding vessels and lamina propria. An immunohistochemical stain confirmed the presence of cytomegalovirus (CMV) in the duodenum (Figure, Panel B).

Figure—CMV (arrows) in the duodenum revealed by (A, left) hematoxylin–eosin stain and (B, right) immunohistochemical stain (400x).

Points to remember: CMV is a double-stranded DNA virus that tends to infect the vasculature, causing endotheliolitis, submucosal ischemia, and secondary ulceration. Infection with CMV in immunocompromised patients can result in serious, often fatal, disease.

CMV infection should always be part of the differential diagnosis in patients who develop gastrointestinal symptoms or ulcerative lesions after bone marrow transplantation. Correct diagnosis is important so that prompt treatment with gancyclovir can be initiated.

Diagnosis: Cytomegaloviral duodenitis.