Multiple Small Bowel and Colonic Perforations Secondary to Cytomegalovirus Infection in a Newly Diagnosed AIDS Patient

Cytomegalovirus (CMV) primarily affects immunocompromised individuals and can rarely involve the small bowel, causing deep ulcerations and microperforations. This is most commonly observed in patients with AIDS and CD4 counts below 50 cells/μL who are not receiving antiretroviral therapy (ART). Due to diagnostic challenges and the risk of severe complications, CMV gastrointestinal (GI) disease is associated with high morbidity and mortality. We report the case of a 38-year-old woman from Ecuador, four months postpartum with an unknown cause of infant demise, who presented with a 15-day history of abdominal pain, diarrhea, vomiting, and hypotension. Two exploratory laparotomies revealed multiple small bowel and colonic microperforations requiring bowel resections. CMV leads to both small bowel and colonic perforations primarily through a combination of direct viral cytopathic effects and ischemic injury secondary to vasculitis. Infectious evaluation revealed a new diagnosis of AIDS, and final surgical pathology was positive for CMV. The patient initially recovered from surgery and was started on appropriate systemic therapy, but ultimately left the hospital against medical advice and was noncompliant with ART. She was readmitted three days later with disseminated intravascular coagulation, GI bleeding, multi-organ failure, and disseminated toxoplasmosis. The patient ultimately passed away approximately 45 days after initial presentation. This case underscores the complexities of managing CMV GI disease. Early recognition of immunity status is crucial to broadening the differential to include opportunistic infections. Timely diagnosis and initiation of therapies with good patient compliance could significantly impact outcomes.