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Abdomen » Gastrointestinal
Cytomegalovirus enteritis
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Presentation A 45 year old male who is a recovered drug addict and HIV positive, presents with acute crampy abdominal pain and diarrhea. An abdominal ultrasound was performed.
Caption: Transverse view of the left mid-abdomen
Description: This view demonstrates thickened echogenic walls of the bowel loops. There is also a small amount of free fluid noted.
Caption: Transverse view of the left mid-abdomen
Description: This image also demonstrates the thickened bowel loops with the free fluid.
Differential Diagnosis The differential diagnoses of small bowel wall thickening include inflammatory bowel disease, acute ileitis [Yersinia or Campylobacter], postoperative edema, peritoneal carcinomatosis and mesenteric infarction.

Uncommon causes include HIV enteropathy [CMV, MAI or cryptosporidium], intestinal hematoma, intussusception, tuberculosis, eosinophilic enteritis, neutropenic enterocolitis.
Final Diagnosis Cytomegalovirus enteritis in an HIV patient
Discussion Diarrhea in an HIV infected patient can occur secondary to various reasons, most of which have been described above in the differential diagnoses.

This case illustrates the appearance of bowel wall thickening that is seen in cytomegalovirus infection of the bowel. Of particular interest is the fact that the thickened bowel wall appears highly echogenic, especially the mucosal layer. A recent study by Hollerweger, et al. described this appearance of the bowel wall occurring in patients with HIV and described it as the ‘white bowel’ sign. This sign was described in a variety of conditions, and was not specific to any one particular disease process. The author attributed this hyperechoic appearance to lymph edema of the bowel wall.

Another study by Frisoli, et al  correlated the sonographic appearance of bowel wall with the acuity of the underlying disease process. Our observations in this case corroborated with their findings, which suggested that increased thickness of the echogenic submucosal layer indicates an acute disease process related to either submucosal edema or submucosal hemorrhage.
Case References 1. Frisoli JK, Desser TS, Jeffrey RB. Thickened submucosal layer: a sonographic sign of acute gastrointestinal abnormality representing submucosal edema or hemorrhage. 2000 ARRS Executive Council Award II. American Roentgen Ray Society. AJR. 2000 Dec; 175(6):1595-9.
2. Hollerweger A, Dietrich CF. ["White bowel". A sonographic sign of intestinal lymph edema?] Ultraschall Med. 2005 Apr; 26(2):127-33.
Follow Up This patient had biopsy and culture proven cytomegalovirus infection and responded well to medical management.
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