A rare cause of severe esophagitis in an immunocompetent patient: double complication with an endoscopic resolution

A 75-year-old male, without relevant medical history and negative HIV1/2 serology, presented at the emergency department with mixed shock (septic - from pleuroparenchymal origin - and hypovolemic due to upper gastrointestinal bleeding [UGIB]). Thoracoabdominal CT scan showed an esophagopleural fistula (EPF), with a large right pleural effusion (lately known to be compatible with exudate - Light's criteria) and right pneumothorax, without active bleeding. The upper gastrointestinal endoscopy (UGIE) showed a severe esophagitis and, in distal oesophagus, an ulcer with an orifice in the center. Biopsies of the edges of the ulcer were performed. Anatomopathological (AP) studies were negative for viral agents but tissue molecular studies (polymerase chain reaction [PCR]) identified cytomegalovirus (CMV) DNA. Despite no immunosuppression condition was identified, CMV severe esophagitis complicated by EPF with right-side empyema and UGIB was diagnosed. An oesophageal fully covered metal stent (FCMS), with anti-migration system, was left in place during 5-weeks and ganciclovir therapy (5mg/kg/day) was maintained for 21-days. Clinical-analytical, radiological and endoscopic improvement was noticed. No recurrence in the following year of follow-up.