Cytomegalovirus Enteritis after Surgery for Acute Type A Aortic Dissection Complicated by Malperfusion and Thymoma: A...

Cytomegalovirus (CMV) enteritis is a potentially life-threatening gastrointestinal infection typically observed in immunocompromised individuals, such as transplant recipients or patients receiving chemotherapy or long-term corticosteroids. However, CMV enteritis can also develop in the absence of overt immunosuppression, particularly in elderly or critically ill patients under physiological stress, nutritional decline, or prolonged hospitalization. Diagnosis in these settings is challenging because clinical symptoms and imaging findings are nonspecific and may overlap with ischemic or other infectious enteritis.

We report a rare case of CMV enteritis in a 65-year-old man who underwent emergent surgical repair for acute type A aortic dissection complicated by superior mesenteric artery (SMA) malperfusion. He underwent total arch replacement, aortic valve replacement with a bioprosthetic valve, and concomitant thymectomy for an anterior mediastinal mass. On POD 4, additional endovascular interventions were performed, including thoracic endovascular aortic repair and SMA stenting. His postoperative course was notable for persistent ileus, poor oral intake, progressive nutritional deterioration, and sustained postoperative fever with elevated inflammatory markers. Because these symptoms and inflammatory findings persisted without an identified infectious source, CMV testing was performed on POD 20. The results, which became available on POD 23, showed positive CMV antigenemia (C7-HRP: 42/50000 WBC) and CMV DNA (1.2 × 10⁴ IU/mL). Abdominal CT demonstrated diffuse small-bowel wall thickening and submucosal edema. Because of his clinical status, endoscopic biopsy was deferred, and CMV enteritis was diagnosed presumptively based on clinical, radiologic, and virologic findings. Intravenous ganciclovir (300 mg every 12 hours) was initiated and continued for 22 days, resulting in gradual improvement in abdominal symptoms, a marked decrease in CMV DNA levels, and conversion of CMV antigenemia to negative. He was transferred to another facility on POD 90.

CMV enteritis should be considered as a cause of unexplained postoperative fever after open-heart surgery, particularly following repair of acute aortic dissection complicated by malperfusion-related intestinal ischemia, even without classic immunosuppressive conditions. Surgical stress, ischemic bowel injury, and delayed nutritional recovery may predispose critically ill postoperative patients to CMV reactivation. Early CMV testing and timely antiviral therapy may facilitate diagnosis and help prevent clinical deterioration.