A PECULIAR ENCEPHALOPATHY: A RARE CASE OF PNEUMATOSIS INTESTINALIS SECONDARY TO CYTOMEGALOVIRUS C Parent MD, R Goel MD, L Bateman MD Department of Medicine, Ochsner Medical Center, New Orleans, Louisiana INTRODUCTION Pneumatosis intestinalis (PI) is characterized by the formation of gas within the walls of the intestines. It has a poorly understood pathophysiology. The rarity of PI and the lack of defined treatment recommendations may present a challenge for clinicians both in terms of diagnosis and deciding on appropriate management. CASE: A 74-year-old man renal transplant patient presented with a two-month duration of decreased appetite and progressively worsening altered mental status associated with new short-term memory deficits and intermittent confusion. His physical examwas significant for encephalopathy but with an unremarkable abdominal exam. His initial laboratory work-up showed an elevated creatinine with normal electrolytes, thyroid function, and ammonia levels. He tested negative for BK virus, HIV, and syphilis. Computed tomography of the head and magnetic resonance imaging of the brain were unremarkable. Chest X-ray ordered to rule out infectious etiology of encephalopathy incidentally detected air within the wall of the colon at the hepatic flexure. A follow-up CT of the abdomen confirmed air within the wall of the ascending colon and proximal transverse colon consistent with PI. The patient underwent right sided hemicolectomy and ileostomy creation. Pathology of the resected colon was negative for malignancy but ultimately revealed evidence of cytomegalovirus. In addition, blood cultures later revealed disseminated Candida albicans felt secondary to possible bowel micro-perforation. He was treated and improved following a two-week course of Ganciclovir and a prolonged course of Micafungin. DISCUSSION: PI has been linked to a wide variety of etiologies from the rupture of COPD blebs to ischemic bowel to fungal overgrowth. Because it represents such a wide spectrum of diseases, rapid evaluation may be difficult and requires the involvement of a multidisciplinary team in conjunction with targeted imaging modalities to make the diagnosis.
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