S3470 Beyond the Colon: Hepatobiliary CMV as a Rare End-Organ Manifestation of AIDS

Introduction: Cytomegalovirus (CMV) is a common opportunistic infection in patients with advanced HIV/AIDS. While gastrointestinal involvement is well-documented, hepatobiliary CMV remains an exceptionally rare form of end-organ disease. We present a case of hepatobiliary CMV in an immunocompromised patient with concurrent colitis and profound liver enzyme elevation, confirmed via liver biopsy. Case Description/Methods: A 31-year-old man with AIDS (CD4 <200) and history of crack cocaine use presented with 1 week of right lower quadrant abdominal pain, nausea, vomiting, diarrhea, and hematochezia. He had been out of HIV care for over a year after previously being on Biktarvy and Prezcobix. He reported 20–30 lb weight loss over 3 months. Computed tomography abdomen/pelvis revealed findings consistent with colitis. Initial stool studies were positive for cryptosporidium, and nitazoxanide was initiated. Notably, liver function testing revealed ALP 1197 U/L and GGT 952 U/L with normal LDH and bilirubin. Computed tomography and magnetic resonance cholangiopancreatography (MRCP) showed heterogeneous liver enhancement, multiple ring-enhancing hepatic lesions, and intrahepatic biliary ductal dilation with a normal common bile duct. Magnetic resonance imaging demonstrated a 6.6 × 2.7 cm arterial-phase enhancing hepatic lesion. Liver biopsy confirmed CMV inclusion bodies, and quantitative CMV PCR was >1000 IU/mL, meeting criteria for end-organ involvement. Ganciclovir was initiated and transitioned to valganciclovir 900 mg twice a day. After 21 days of antivirals, his valganciclovir was reduced to 900 mg daily per protocol. Patient was discharged with outpatient follow up. Discussion: This case highlights a rare manifestation of CMV end-organ disease involving the hepatobiliary system in a severely immunocompromised patient. The patient presented with nonspecific GI symptoms, cryptosporidiosis, and liver enzyme elevation out of proportion to transaminases. Imaging findings were atypical and prompted biopsy, which confirmed hepatobiliary CMV. Treatment included antiviral therapy. This case underscores the importance of a broad differential, timely biopsy, and multidisciplinary care in managing complex presentations of AIDS-related GI and hepatobiliary disease.