Large bowel perforation due to cytomegalovirus colitis in a post-cardiac surgical patient on chronic hemodialysis

Background: Cytomegalovirus (CMV) colitis with colonic perforation is an exceedingly rare but life-threatening condition. The most comorbid diagnosis in patients with perforated CMV colitis is human immunodeficiency virus in the setting of advanced immunosuppression associated with CD4 < 50 cells/μL.

Case presentation: A 75-year-old female with a ≥ 30-year history of hemodialysis presented with progressive dyspnea on exertion. Transthoracic echocardiography showed moderate mitral stenosis and severe aortic stenosis. Although she was a high-risk candidate with a risk for mortality of 17.17% and morbidity and mortality both of 35.63% in The Society of Thoracic Surgeons risk calculator, we performed mitral and aortic valve replacement with both biological valves. Postoperative course was complicated with a high dose of inotropic support, cardiac tamponade requiring open drainage, and the need for a tracheostomy. Abdominal distension was observed, and enhanced computed tomography demonstrated free air and a suspected perforated sigmoid colon. Emergency laparotomy revealed a 20-cm longitudinal perforation in the sigmoid colon. A left hemicolectomy with stoma was performed. Immunostaining of a sample of her colon showed cytomegalovirus-positive cells.

Conclusions: Cardiac surgeons should consider cytomegalovirus colitis as a differential diagnosis during the course of cardiac surgery even in immunocompetent patients.