An 85-year-old patient with a history of hypertension, dyslipidemia, acute myocardial infarction with residual ventricular aneurysm, transient cerebral ischemic accidents, benign prostatic hyperplasia and renal cysts with normal renal function.
No toxic habits.
In treatment with Lopresor®, Adiro® and Urolosin®.
No previous surgical interventions.
The patient came to the gastrointestinal tract with a 15-day history of episodes of colic, non-irradiated, periumbilical abdominal pain, occasional vomiting, and occasional vomiting.
He had no fever or altered bowel rhythm.
Blood tests were performed, highlighting: glucose 119 mg/dl, urea 22 mg/dl, creatinine 1.14 mg/dl, sodium 142 mmol/l, potassium 4.3 mmol/l, hemoglobin 13,2 μg/dl mean platelet count
Gastroscopy showed a hiatal hernia with preserved mucosa, as well as areas of intestinal metaplaisa in the stomach with superficial erosions and negative urease test, and abdominal ultrasound showed no significant findings.
Subsequently, due to the increase in symptoms accompanied by fever, it was decided to admit the patient.
Sepsis was performed, in which up to 3-4 cm of terminal ileum were explored without progressing further by stenosis and computed tomography where 18 cm long ileum stenosis was observed.
After performing the CT, the patient began with signs of peritoneal irritation and dyspnoea on abdominal examination, for which reason, after evaluation by the surgery service, urgent surgical intervention was decided.
Resection of the ileum and apexectomy were performed.
The intestinal resection specimen showed a stenosed segment with thickened walls of firm consistency, measuring 8 cm in the longitudinal axis and coinciding, after opening, with an area of extensive mucosal ulceration.
Pathological examination showed areas of preserved mucosa with marked inflammatory changes, mainly cryptic distortion, with mild loss of mucosecretion of the epithelium, superficial lymphangiectasia and lymphoplasmacytic infiltration of the entire epithelium.
In ulcerated foci, granulation tissue was observed and focally reepithelialized, where occasional large eosin cells surrounding large endothelial cells with granular halophilic inclusions and nucleus were observed.
The presence of cytomegalovirus infection in these cells was demonstrated by immunohistochemical techniques.
After surgery, the patient was successfully treated with anti-viral drugs and discharged, remaining asymptomatic and without specific treatment.
