Potentially fatal hemorrhagic duodenal ulcers caused by cytomegalovirus infection complicating autoimmune hepatitis with acute liver failure, successfully treated with multiple interventional radiology procedures.

Abstract

Cytomegalovirus (CMV)-associated gastrointestinal disease can precipitate life-threatening hemorrhages; therefore, heightened vigilance is warranted in patients administered immunosuppressive agents. Moreover, acute liver failure compromises cellular immunity by disrupting immune regulatory mechanisms. Herein, we describe a case of duodenal ulcer caused by CMV reactivation during treatment for autoimmune hepatitis (AIH), complicated by acute liver failure. The patient was admitted with acute-onset AIH and steroid pulse therapy was initiated; however, progression to acute liver failure followed. Although acute liver failure improved after plasma exchange and continuous hemodiafiltration, multiple duodenal ulcers developed owing to CMV reactivation following the introduction of azathioprine. Subsequently, the patient developed a microperforation, which resolved with conservative management. However, gastrointestinal bleeding occurred at multiple sites, making endoscopic hemostasis difficult. As the patient's general condition was poor, and surgical intervention was deemed infeasible, interventional radiology (IVR) was conducted thrice within a single day, successfully achieving hemostasis and ultimately saving the patient's life. Although immunosuppressive therapy is indispensable for AIH management, caution regarding CMV reactivation is required during the development of acute liver failure. Furthermore, IVR is a minimally invasive modality that can be performed repeatedly, making it an effective therapeutic option for managing gastrointestinal bleeding.