P0232 - This Fistula Just Went Viral

Surya Khadilkar, MD¹, Erik Holzwanger, MD², Rohit Dhingra, MD¹, Dailey Joseph, MD¹, Sushrut Jangi, MD¹, Harmony Allison, MD^1
1Tufts University Medical Center, Boston, MA; ²Tufts University Medical Center, Brighton, MA

Introduction: Colorenal fistulas are rare phenomena that require a multidisciplinary approach. While they have been described as complications related to percutaneous cryoablation of renal cell carcinoma (RCC), it has not been reported with cytomegalovirus (CMV) colitis. We present an unusual case of a left colorenal fistula in the setting of severe CMV colitis.

Case Description/Methods: A 48-year-old woman with history of HIV on antiretroviral therapy, diffuse large B cell lymphoma (DLBCL) treated with chemotherapy in remission and non-ischemic cardiomyopathy (ejection fraction 15%) presented with acute decompensated heart failure. She developed diarrhea during her hospital course and a C. difficile stool toxin was positive. She initiated oral vancomycin with improvement of her diarrhea. For pre-cardiac transplant evaluation, CT imaging was pursued to confirm eradication of DLBCL. This revealed a fluid collection directly contiguous with the adjacent renal cortex concerning for a left colorenal fistula with abscess formation. Subsequent colonoscopy revealed localized moderate inflammation and a fistula in the descending colon. Pathology from the colorenal fistula contained fragments of granulation tissue with nuclear changes and immunohistochemical stain was positive for CMV.

Discussion: AIDS-related CMV gastrointestinal (GI) disease has become less common with the implementation of antiretroviral therapy. It does occur in up to 5% of AIDS patients and tends to occur with a CD4 cell count < 50 cells/microL. AIDS-related CMV GI disease encompasses multiple areas within the GI tract, with the large intestine being the most common. Common presenting symptoms of CMV colitis include fevers, abdominal pain, diarrhea, hematochezia and unintentional weight loss. Colorenal fistulas have yet to be reported as a complication of CMV colitis. These can be difficult to manage in the setting of an immunocompromised state and acute inflammation with therapies ranging from conservative to more aggressive surgical interventions. We would recommend initiation of antivirals, such as ganciclovir, with consideration of surgical intervention after completion of treatment. Depending on the fistula location and size, colonic stenting or over-the-scope clips could be considered. In summary, we present the first reported case of AIDS-related CMV colitis leading to a colorenal fistula. Early multidisciplinary discussion is imperative for optimal treatment.


Disclosures:


Surya Khadilkar, MD¹, Erik Holzwanger, MD², Rohit Dhingra, MD¹, Dailey Joseph, MD¹, Sushrut Jangi, MD¹, Harmony Allison, MD¹. P0232 - This Fistula Just Went Viral, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.