Methods
Differential diagnoses for the patient include Gastrointestinal
Bleeding, Peptic Ulcer Disease, Drug-Induced Nephrotoxicity, and
infections.
The patient’s initial tests showed an increase in creatine numbers. An
upper gastrointestinal endoscopy was performed, which revealed
inflammation at the end of the esophagus, a thickened fundus, a 3 cm
deep atrophic ulcer on the superior side of the pylorus, and an
edematous pylorus. A biopsy was taken, and the patient was placed on
appropriate treatment and discharged pending the results of the biopsy.
Furthermore, creatinine numbers began to decrease. Five days later, the
patient was admitted to the hospital due to watery diarrhea, weakness,
asthenia, anorexia, oliguria, dysphagia, and back pain, with no fever.
On clinical examination, blood pressure was 130/70 mm Hg, heart rate 85
bpm, saturation 98%, axillary temperature 36.2°C, paleness, soft purrs
in the left lung more than the right lung with no wheezing, generalized
reluctance, and pain in the abdomen, which was mostly located in the
left and right iliac fossa, with no signs of deep venous thrombosis
(DVT). Electrocardiography (ECG) and digital rectal examinations (DRE)
were normal. The laboratory exam was analyzed as shown in Table {1}.
The biopsy revealed signs of chronic gastritis, erosive ulcers, negative
for HP, eosinophilic intranuclear inclusions, variable granular purple
cytoplasmic inclusions, and no malignancy. A CMV-polymerase chain
reaction (PCR) was requested, which came back positive. The diagnosis
was acute renal failure and chronic CMV gastritis. Other laboratory
tests, including urine culture, diagnosed a Klebsiella urinary tract
infection, which was found unrelated. The patient was treated with
intravenous ganciclovir 200 mg, metronidazole 200 mg, levofloxacin 250
mg, Ceftriaxone 1g, mycophenolate 500 mg, cyclosporine 100 mg,
Prednisolone 20 mg, Angiotensin Receptor Blokker 160 mg, Amlodipine
besylate 10 mg, Furosemide 40 mg, Omeprazole 40 mg, spasmo (Dicyclomine
+ Paracetamol + Tramadol), nystatin, and insulin. The general condition
improved, and the patient was discharged two weeks later with no signs
of DVT. Five days later (22 days after the initial CMV infection), the
patient presented to the hospital complaining of fatigue, weakness,
fever, chills, drowsiness, back pain, and hypotension. The clinical exam
showed pitting edema (+4), redness, pain, calf rigidity, and increased
skin temperature in the lower right limb. The abdominal examination
showed a generalized reluctance, mostly located in the right
hypochondria. ECG revealed normal sinus rhythm, left axis deviation,
left ventricular hypertrophy, and T wave inversion in v1 to v6, I, and
aVL. A transthoracic echocardiogram (TTE) showed severe hypertrophy in
the septal wall of about 27 mm and severe apical and septal hypokinesis.
Echo Doppler of the right leg showed acute thrombosis in the right
femoropopliteal vein. Head computed
tomography
(CT) was normal. A laboratory examination is shown in Table {2}.
Regrettably, in the context of the medical infrastructure in Syria,
comprehensive testing, particularly for specialized conditions such as
cryoglobulinemia, faces significant challenges. The economic hardships
experienced by the patient and his family further compounded the
situation, rendering them unable to afford the necessary diagnostic
tests, which are not locally available. Additionally, the precarious
situation in the country and the unfortunate financial constraints
deterred any possibility of seeking these tests in neighboring
countries.
Given these circumstances, despite the clinical relevance of a
cryoglobulinemia test in confirming the diagnosis of CMV-related DVT, it
was practically unfeasible to pursue this diagnostic avenue.
Consequently, the clinical diagnosis of CMV-related DVT was established
based on the patient’s unilateral symptoms, the timing of DVT onset in
correlation with the initial CMV infection, and concomitant urinary
tract infection. DVT was treated with Memantine 20mg twice daily, leg
elevation, and absolute rest in addition to his drugs
and
continuous therapy of ganciclovir
200mg.Conclusion and resultsOn follow-up one week later, the patient developed superficial vein
thrombosis in his right arm and was treated and left to rest. On
further follow-up the patient remains well with a well-functioning graft
and is free of evidence of CMV.