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.