A Rare Case of Esophageal Pseudodiverticulosis Associated With Cytomegalovirus Esophagitis Presenting With Severe Upper Gastrointestinal Bleeding

CASE REPORT A 53-year-old man with a medical history of HIV and gastroesophageal reflux disease presented with hematemesis and melena. Esophagogastroduodenoscopy revealed large amounts of clotted blood with multiple deep pits and cavities suggesting esophageal pseudodiverticulosis throughout the esophagus (Figure 1). Subsequent esophagogastroduodenoscopy revealed active bleeding from visible vessels within 2 pseudodiverticula. This was treated with injection of epinephrine and 2 through-the-scope clips, followed by an over-the-scope clip due to persistent bleeding. Histopathology revealed intraepithelial lymphocytes and eosinophils as well as cytomegalovirus (CMV) inclusions on immunohistochemical stain. Treatment included initiating ganciclovir followed by an extended course of valganciclovir 900 mg twice daily and oral pantoprazole 40 mg twice daily at discharge.Figure 1.: (A) Deeply pitted and cavitary esophageal ulceration filled with a large amount of clotted blood throughout the esophagus. (B) Extensive esophageal pseudodiverticulosis revealed throughout the esophagus after the removal of large clotted blood.CMV esophagitis can lead to well-demarcated, linear, and shallow ulceration in the middle to distal third of the esophagus.1,2 The progression to extensive and “punched out” cratered ulcers signifying esophageal pseudodiverticulosis is rare.1–3 Risk factors for CMV esophagitis are immunocompromised states, candidiasis, gastroesophageal reflux disease, malignancy, organ transplant, and other chronic inflammatory states.1,2,4 In our patient, the advancement to esophageal pseudodiverticulosis occurred rapidly over a month, which may indicate a severe form of CMV infection. Immediate treatment is necessary to potentially prevent life-threatening upper gastrointestinal bleeding. DISCLOSURES Author contributions: K. Patel: Article guarantor. Participated in study concept and design, acquisition of data, interpretation of data, writing, technical editing/reviewing, and submission of the manuscript. J. Jan: Participated in acquisition of data, interpretation of data, drafting of the manuscript, and critical revision of the manuscript. B. Glessing: Participated in acquisition of data, interpretation of data, and critical revision of the manuscript. G. Cooper: Participated in interpretation of data, drafting of the manuscript, and critical revision of the manuscript. Financial disclosure: None to report. Previous presentation: Poster presentation at ACG 2024 Annual Meeting, October 28, 2024, Philadelphia, Pennsylvania. All attempts have been exhausted in trying to contact the patient, next of kin, and/or parent/guardian for informed consent to publish their information, but consent could not be obtained.