Safety of Bronchoscopy in Patients with Echocardiographic Evidence of Pulmonary Hypertension.

BACKGROUND: Bronchoscopy with transbronchial and endobronchial biopsy and transbronchial needle aspiration is an important diagnostic tool in the pulmonologist's armamentarium. Safety in patients with pulmonary hypertension is controversial and many bronchoscopists consider this as a contraindication for the procedure. OBJECTIVES: To evaluate safety of bronchoscopy in patients with echocardiographic pulmonary hypertension and to compare with patients without it. METHODS: Retrospective analysis of patients who underwent bronchoscopic transbronchial biopsy, endobronchial biopsy and/or endobronchial ultrasound-guided transbronchial needle aspiration. Patients were divided into two groups based on echocardiographic results: control group with systolic pulmonary artery pressure <36 and a group with elevated systolic pulmonary artery pressure (eSPAP) ≥36. RESULTS: One-hundred and ninety patients met the study criteria. Patients in the control group were younger with a lower incidence of chronic kidney disease. There was no difference in prevalence of congestive heart failure, obstructive airway disease, malignancy, liver disease, coagulopathy, use of antiplatelet agent or anticoagulant drugs. Incidence of minor bleeding due to bronchoscopic biopsies was 4.8% in both groups (p = 1.00). Incidence of major bleeding was similar in the groups (one patient in each group). In the control group, one patient had pneumothorax and another required prolonged mechanical ventilation (>4 h). In the eSPAP group, two patients required prolonged mechanical ventilation. There was no procedure-related mortality or sedation complications in the cohort. CONCLUSION: Our study provides additional support that in patients with echocardiographic evidence of pulmonary hypertension, transbronchial and endobronchial biopsies and endobronchial ultrasound-guided transbronchial needle aspiration are safe procedures.

Pulmonary alveolar proteinosis following severe COVID - 19 infection: A case report.

A 67-year-old male, with a history of severe COVID-19 infection and exposure to talc was seen for worsening shortness of breath for months, requiring supplemental oxygen. He was treated for COVID-19 infection and suspected pneumonia with no improvement. His pulmonary function test (PFT) worsened and computed tomography (CT) showing bilateral airspace opacities with ground-glass opacities (GGO), also worsened over time. He underwent bronchoscopy, bronchoalveolar lavage and pathology revealed pulmonary alveolar proteinosis (PAP). He subsequently underwent whole lung lavage (WLL) which significantly improved his crazy paving pattern on CT and was successfully weaned off supplemental oxygen.

Outcomes of patients with non-diagnostic bronchoscopy: A clinico-radiological comparison of patients with diagnostic and non-diagnostic bronchoscopy.

Bronchoscopy is one of the most common diagnostic procedures in pulmonary practice. Data on the outcome of patients following a non-diagnostic bronchoscopy are sparse. Diagnostic yield depends on indication, the characteristics of patients, and the chest imaging. The aim of this study was to evaluate the outcomes of patients with a non-diagnostic bronchoscopy and to compare patients who had a diagnostic with those that had a non-diagnostic bronchoscopy.Retrospective, single-center study of adult patients who underwent bronchoscopy with transbronchial biopsy (TBBX) and/or endobronchial biopsy (EBBX), endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), or brushing. A strict definition for a "diagnostic" bronchoscopy was used. Univariate and multivariate analyses were performed.A total of 684 patients were identified, 350 (51%) had a diagnostic procedure. Of the 334 patients with a non-diagnostic bronchoscopy, 196 (58.6%) were followed, but only 172 (88%) completed 1 year of follow-up. Most of the patients (57.8%) had resolution or stabilization of the condition; in the remaining patients, malignancy was most commonly diagnosed after further investigation followed by diffuse lung diseases and infections. Pulmonary tuberculosis was diagnosed in 8 patients. EBUS-TBNA and EBBX were the procedures associated with a diagnostic bronchoscopy. Presence of bilateral interstitial infiltrates predicted a non-diagnostic bronchoscopy.A significant number of patients with non-diagnostic bronchoscopy may have serious treatable disease that is identified upon further investigation. Close follow up of patients with a non-diagnostic procedure is warranted. Our study found no clear clinical or radiological predictors of diagnostic bronchoscopy.

Preclinical cardiac disease in nonalcoholic fatty liver disease with and without metabolic syndrome.

BACKGROUND: Metabolic syndrome is associated with preclinical cardiac disease and nonalcoholic fatty liver disease (NAFLD). It is uncertain whether preclinical cardiac disease is present in patients with NAFLD without metabolic syndrome (MetS). OBJECTIVE: To explore preclinical cardiac disease in patients with NAFLD. METHODS: A total of 64 patients with NAFLD, based on computed tomography scans liver attenuation, were identified. A control group, matched to age and gender, comprising of 94 patients was also drafted. Finally, two additional groups of patients with metabolic syndrome, with (n = 40) and without (n = 74) NAFLD, were also identified. Patients with hypertension, diabetes mellitus, and other concomitant liver diseases were excluded from the NAFLD group. Echocardiograms of all groups were reviewed. RESULTS: Severe NAFLD compared to control was associated with a higher left ventricular mass after normalization for height2.7 (LVMHt2.7) (95% CI = 0.39, 12.92) and lower ratio of peak "E" (early) and "A" (late) diastolic ventricular filling velocities (E/A) - 0.39 (95% CI = -0.58, -0.19). Patients with metabolic syndrome (95% CI = 0.02, 0.09), metabolic syndrome with NAFLD (95% CI = 0.02, 0.08), or severe NAFLD (95% CI = 0.02, 0.09) compared to control was associated with a higher relative wall thickness (RWT). CONCLUSION: Healthy adults with NAFLD without metabolic syndrome, after adjusting for body mass index, demonstrated significant echocardiographic changes. Our results show that NAFLD is associated with preclinical cardiac disease, and this association is independent of traditional risk factors like systemic hypertension and diabetes mellitus.

A Case of Concomitant Obstructive Sleep Apnea and Non-Alcoholic Steatohepatitis Treated With CPAP Therapy.

Obstructive sleep apnea syndrome is a disorder of sleep breathing that is a result of recurrent and intermittent hypoxia during sleep induced by the repeated partial or complete collapse of the upper airway, eventually causing chronic intermittent hypoxia. Non-alcoholic fatty liver disease is divided into non-alcoholic fatty liver and non-alcoholic steatohepatitis. Animal and human studies showed that obesity is associated with chronic liver hypoxia, even in the presence of systemic normoxia causing inflammation and release of cytokines. A "two-hit" model has been proposed. The first hit is characterized by insulin resistance and excess hepatic lipid accumulation secondary to abnormal fatty acid metabolism. Oxidative stress and inflammation are thought to comprise the second hit. Gold standard for the diagnosis of non-alcoholic steatohepatitis is a liver biopsy. Many clinical scores and non-invasive tools are used for the diagnosis of non-alcoholic steatohepatitis. Conservative management with lifestyle modifications including diet, exercise and weight loss remains the therapy of choice today. We present a case report of a 39-year-old man who was diagnosed with concomitant non-alcoholic steatohepatitis and severe obstructive sleep apnea. He was started treatment with continuous positive airway pressure and demonstrated excellent adherence to therapy for 6 years, with concomitant obstructive sleep apnea and non-alcoholic steatohepatitis which reversed with prolonged optimal continuous positive airway pressure therapy. Physical examination remained unremarkable except for morbid obesity. His abdominal girth, as well as body mass index, remained unchanged. After 6 years of optimal continuous positive airway pressure therapy, liver enzymes and relevant lipid panel normalized, suggesting reversal of non-alcoholic steatohepatitis.

Diffuse Alveolar Hemorrhage without Extrapulmonary Manifestations: A Rare Presentation of Lupus.

BACKGROUND Diffuse alveolar hemorrhage (DAH) is a life-threatening disorder resulting in hemorrhage into the lungs due to a variety of reasons. The underlying etiology for DAH is broadly divided into immune and non-immune mediated causes. Rheumatological disorders account for a small number of cases. Although hemoptysis is one of the alarming symptoms of DAH, it is absent in a third of the cases. Diagnosis often requires a conglomerate of history, clinical, and laboratory investigation and radiological studies. CASE REPORT We describe a case of a 31-year-old female who had an atypical presentation of systemic lupus erythematosus (SLE) with primary lung involvement/DAH and no other organ involvement. CONCLUSIONS This case report illustrates the importance of awareness and early recognition of the complication that can prevent mortality.

Mycoplasma pneumoniae: A Potentially Severe Infection.

Mycoplasma pneumoniae infections remain one of the most common etiologies of community-acquired pneumonia (CAP). The clinical presentation and manifestations vary widely and can affect all organs of the body. Diagnosis is challenging because there are no constant findings in physical exams or laboratory or radiological assessments that indicate Mycoplasma pneumoniae pneumonia, and specific diagnostic tools are not readily available. Extrapulmonary manifestations and severe pulmonary manifestations can lead to long-term sequelae. The increasing emergence of Mycoplasma pneumoniae that is resistant to macrolides in some areas of the world and increased world travel could add to the difficulty of controlling and treating Mycoplasma pneumoniae infections. We present a concise and up-to-date review of the current knowledge of Mycoplasma pneumoniae pneumonia.

Mycoplasma Pneumoniae Pneumonia: Walking Pneumonia Can Cripple the Susceptible.

BACKGROUND: Mycoplasma pneumoniae pneumonia (MPP), or "walking pneumonia," is an atypical mild disease with varied clinical findings. Specifically, diagnosis is often controversial and understanding of disease presentation is limited. The goal of the study was to evaluate presentation, clinical associations and outcomes of MPP patients admitted to an inner-city hospital. METHODS: This was a retrospective analysis of adult patients diagnosed with MPP from January 2010 to January 2017. Primary outcomes were need for intensive care unit (ICU) care, ICU and hospital length of stay (LOS), presence of shock and need for mechanical ventilation (MV). Predictors of mortality were analyzed. RESULTS: Of the 203 patients analyzed, 16 (8%) died. Relative to survivors, non-survivors were older (65 ± 21 versus 53 ± 18, P = 0.009) and less frequently had obstructive airway disease (OAD; P = 0.003). Non-survivors also had significantly higher serum levels of lactic dehydrogenase (LDH), blood urea nitrogen (BUN), creatinine, transaminases and troponins. Finally, non-survivors more commonly exhibited shock, need for MV and bilateral lung infiltrates. There were no group differences in patient comorbidities, symptoms, antibiotic use or LOS. Predictors of mortality included age, OAD, low CD4+ T-cell counts in human immunodeficiency virus-infected patients and elevated serum levels of LDH, creatinine, BUN, leukocytes, transaminases and troponins. CONCLUSION: Despite the availability of appropriate antibiotics, MPP incurs significant mortality and morbidity. Our study indicated that the recommended treatment includes prompt serological diagnosis, aggressive supportive care and presumptive antibiotics, especially in patients with poor prognosis.

Critical Management of Severe Hypotension Caused by Amlodipine Toxicity Managed With Hyperinsulinemia/Euglycemia Therapy Supplemented With Calcium Gluconate, Intravenous Glucagon and Other Vasopressor Support: Review of Literature.

Calcium channel blocker (CCB ) overdose, whether intentional or accidental, is a common clinical scenario and can be very lethal. Conventional treatments for CCB overdose include intravenous (IV) fluids, calcium salts, dopamine, dobutamine, norepinephrine, phosphodiesterase inhibitors, and glucagon. However, the conventional therapies are unsuccessful in reversing the cardiovascular toxicity of CCB, so they commonly fail to improve the hemodynamic condition of the patient. Blockade of the L-type calcium channels that mediate the antihypertensive effect of CCBs also decreases the release of insulin from pancreatic ß-islet cells and reduces glucose uptake by tissues (insulin resistance). By targeting this insulin-mediated pathway, hyperinsulinemia/euglycemia therapy (HIET) appears to have a distinct role, and its clinical potential is underrecognized in the management of severe CCB toxicity. We present a case of young man with amlodipine toxicity successfully managed with high dose of IV insulin therapy.

Nebulized heparin and N-acetylcysteine for smoke inhalational injury: A case report.

RATIONALE: Every year, ∼40,000 people suffer burn-related injuries in the United States. Despite recent advances, the odds of dying from exposure to fire, flames, or smoke are one in ∼1500. Smoke inhalation causes injury to the airways via a complex physiological process, and the treatment is mainly supportive. Many recent interventions aim to decrease the formation of fibrin casts, the main cause of airway damage in these patients. Among these, treatment with a combination of nebulized heparin and N-acetylcysteine (NAC) has shown benefit. PATIENT CONCERNS: We describe the case of a 58-year-old man who presented after smoke inhalation during a fire. Soot was found in the nostrils when he was admitted to our hospital, and after he began coughing up carbonaceous material, he was electively intubated and placed on volume assist control ventilation. DIAGNOSIS: Bronchoscopy on the first day of intensive care confirmed the injury from smoke inhalation and revealed mucosal edema and soot involving the tracheobronchial tree. INTERVENTIONS AND OUTCOMES: Inhaled unfractionated heparin of 10,000 IU in 3 mL of 0.9% normal saline alternating every 2 hours with 3 mL of 20% NAC was started 48 hours after admission and continued for 7 days. Bronchoscopy on the fifth day of intensive care showed significant improvement in airway edema and a resolution of soot. LESSONS: On the basis of our experience with this case and limited literature, we posit that nebulized heparin and NAC may be of benefit in patients with inhalational smoke-induced lung injury and mild-to-severe lung injury scores.

Rare complicated parapneumonic effusion, Mycoplasma pneumoniae with new-onset lupus flare: Case report and literature review.

Mycoplasma pneumoniae has been associated with respiratory tract infections. Mycoplasma pneumoniae pneumonia-related pleural effusion is rarely reported. Extra-pulmonary abnormalities such as encephalitis, myocarditis, glomerulonephritis, and myringitis have been reported. However pulmonary manifestations in systemic lupus erythematosus include pneumonitis, pleurisy, interstitial lung disease, and thromboembolic disease. We present the case of a 26-year-old male who came for evaluation of fever, cough, and shortness of breath with right-sided chest pain. He was found to have right-side loculated complicated parapneumonic effusion and underwent drainage with a pleural catheter followed by fibrinolytic therapy. He was then found to have new-onset systemic lupus erythematosus concomitant with Mycoplasma pneumonia, leading to lupus flare and lupus nephritis. He responded well to levofloxacin, steroids, hydroxychloroquine, and mycophenolate, with complete resolution of loculated pleural effusion and symptom improvement. Our case describes the rare combination of Mycoplasma pneumoniae pneumonia, parapneumonic pleural effusion, and lupus flare with lupus nephritis. Early identification and treatment can lead to better out come in young patients.

Legionella pneumonia associated with severe acute respiratory distress syndrome and diffuse alveolar hemorrhage - A rare association.

Legionella pneumophila is a common, usually underreported and undiagnosed cause of community acquired pneumonia which can lead to significant morbidity and mortality. Diffuse alveolar hemorrhage rarely have been associated with legionella infection. We present a 61-year-old man with hypertension, diabetes mellitus and obesity admitted with severe acute respiratory distress syndrome. He was found to have Legionella pneumonia with associated diffuse alveolar hemorrhage diagnosed with bronchoscopic sequential bronchoalveolar lavage. He was successfully managed with antibiotics, lung protective strategies and intravenous pulse dose steroids. This patient highlights the unusual association of Legionella infection and diffuse alveolar hemorrhage. Additionally, the case re-enforces the need for early and aggressive evaluation and management of patients presenting with pneumonia and progressive hypoxia despite adequate treatment.

Case report: middle-aged woman from Ghana with unsteady gait and enlarging cerebellar mass.

RATIONALE: Neurosarcoidosis (NS) is an uncommon manifestation of systemic sarcoidosis, with a propensity for middle-agedwomen. Often discovered only at autopsy, rates of neurologic involvement (5%-10%) reported in the literature underscore a lack of sensitivity and specificity in current diagnostic methods. PATIENT CONCERNS: Herein, we describe a 53-year-old woman who presented with gait imbalance and distal extremity muscular weakness. She was known to harbor a brain mass (4 years in duration) that was monitored and recently seemed to enlarge. DIAGNOSIS: A subsequent brain biopsy showed necrotizing granulomatous inflammation suggestive of NS. However, no clinical or radiologic evidence of activity was found in other organs. INTERVENTIONS AND OUTCOMES: Ultimately, endo and transbronchial biopsies were performed, providing histologic confirmation of systemic sarcoidosis. LESSONS: This approach is advised in all instances of suspected NS where systemic involvement is in question.

Transient Left Bundle Branch Block due to Severe Hyperkalemia.

Hyperkalemia is a potentially life-threatening electrolyte imbalance that can lead to sudden death from cardiac arrhythmias and asystole. We present a case of transient left bundle branch block pattern on an electrocardiogram (ECG) secondary to hyperkalemia in a patient with history of end-stage renal disease. A 52-year-old man presented to the emergency room (ER) with chief complaints of weakness and lethargy after missing his regularly scheduled session of hemodialysis. A 12-lead ECG in the ER showed sinus tachycardia at 118 beats/min, wide QRS complexes, peaked T waves and left bundle branch block-like pattern. The initial basic metabolic panel revealed a serum potassium level of 8.8 mEq/L. Subsequently, the patient underwent emergent hemodialysis. Serum chemistry after hemodialysis showed improvement in serum potassium to 4.3 mEq/L. Repeat ECG performed after correcting potassium showed dissolution of left bundle branch block finding.

Significance of NT-pro-BNP in acute exacerbation of COPD patients without underlying left ventricular dysfunction.

BACKGROUND: B-type natriuretic peptide (BNP) and the N-terminal fragment of pro-BNP (NT-pro-BNP) are established biomarkers of heart failure. Increased levels of natriuretic peptide (NP) have been associated with poor outcomes in acute exacerbation of COPD (AECOPD); however, most studies did not address the conditions that can also increase NT-pro-BNP levels. We aimed to determine if NT-pro-BNP levels correlate with outcomes of AECOPD in patients without heart failure and other conditions that can affect NT-pro-BNP levels. METHODS: We conducted a retrospective study in patients hospitalized for AECOPD with available NT-pro-BNP levels and normal left ventricular ejection fraction. We compared patients with normal and elevated NT-pro-BNP levels and analyzed the clinical and outcome data. RESULTS: A total of 167 of 1,420 (11.7%) patients met the study criteria. A total of 77% of male patients and 53% of female patients had elevated NT-pro-BNP levels (P=0.0031). NT-pro-BNP levels were not associated with COPD severity and comorbid illnesses. Log-transformed NT-pro-BNP levels were positively associated with echocardiographically estimated right ventricular systolic pressure (r=0.3658; 95% confidence interval [CI]: 0.2060-0.5067; P<0.0001). Patients with elevated NT-pro-BNP levels were more likely to require intensive care (63% vs 43%; P=0.0207) and had a longer hospital length of stay (P=0.0052). There were no differences in the need for noninvasive positive pressure ventilation (P=0.1245) or mechanical ventilation (P=0.9824) or in regard to in-hospital mortality (P=0.5273). CONCLUSION: Patients with AECOPD and elevated NT-pro-BNP levels had increased hospital length of stay and need for intensive care. Based on our study, serum NT-pro-BNP levels cannot be used as a biomarker for increased mortality or requirement for invasive or noninvasive ventilation in this group of patients.

Tumors Presenting as Multiple Cranial Nerve Palsies.

Cranial nerve palsy could be one of the presenting features of underlying benign or malignant tumors of the head and neck. The tumor can involve the cranial nerves by local compression, direct infiltration or by paraneoplastic process. Cranial nerve involvement depends on the anatomical course of the cranial nerve and the site of the tumor. Patients may present with single or multiple cranial nerve palsies. Multiple cranial nerve involvement could be sequential or discrete, unilateral or bilateral, painless or painful. The presentation could be acute, subacute or recurrent. Anatomic localization is the first step in the evaluation of these patients. The lesion could be in the brain stem, meninges, base of skull, extracranial or systemic disease itself. We present 3 cases of underlying neoplasms presenting as cranial nerve palsies: a case of glomus tumor presenting as cochlear, glossopharyngeal, vagus and hypoglossal nerve palsies, clivus tumor presenting as abducens nerve palsy, and diffuse large B-cell lymphoma presenting as oculomotor, trochlear, trigeminal and abducens nerve palsies due to paraneoplastic involvement. History and physical examination, imaging, autoantibodies and biopsy if feasible are useful for the diagnosis. Management outcomes depend on the treatment of the underlying tumor.

Predictors of acute gastrointestinal bleeding in diabetic ketoacidosis: a retrospective observational study in minority population.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common acute complication of diabetes mellitus requiring aggressive medical management. We attempted to study the incidence and various clinical and laboratory variables associated with acute gastrointestinal bleeding (AGIB) and acute upper AGIB (AUGIB) in patients with DKA. METHODS: We conducted a retrospective chart review of all the patients admitted to our hospital with DKA between January 2010 and December 2015. We collected demographic, clinical, laboratory, endoscopy and hospitalization details using an electronic medical-record database. Patients were divided into two groups based on the occurrence of gastrointestinal bleeding. RESULTS: A total of 234 patients with DKA were admitted during this period, of which 27 (11.5%) patients had documented AGIB. The majority of patients had hematemesis (n=22, 9.4%) except two had rectal and three had occult bleeding. We did not notice any difference in age, gender and ethnicity distribution between the two groups. There was no difference in the serum levels of electrolytes, anion gap, pH and hemoglobin A1C between the two groups. However, patients with AGIB had significantly higher initial blood glucose levels (738 vs 613 mg/dL, p =0.014). There was also increased mortality (7.4% vs 4.8%) in patients with AGIB, but this did not reach statistical significance. CONCLUSION: We conclude that higher initial serum blood glucose was associated with increased incidence of AGIB in patients admitted with DKA. We also noted increased in-patient mortality in patients with DKA who had AGIB, even though statistically insignificant. More aggressive measures to correct blood glucose levels may result in decreased incidence of AGIB, thereby reducing mortality during hospitalization in patients with DKA.

Anemia, intractable vomiting, chronic diarrhea, and syndrome of inappropriate antidiuretic secretion: a diagnostic dilemma: Disseminated strongyloidosis in a patient with newly diagnosed HTLV infection-case report and review of literature.

RATIONALE: Strongyloidiasis hyperinfection and disseminated disease have high mortality rates due to several complications and early detection of Strongyloides infection is therefore prudent. PATIENT CONCERNS: A 37-year-old male patient came with chronic diarrhea, intractable vomiting and was found to have hyponatremia, and anemia on the initial laboratory tests. DIAGNOSES: Further work up revealed syndrome of inappropriate antidiuretic secretion to be the cause of the hyponatremia in addition to gastrointestinal loses. His hospital course was complicated by persistent hyponatremia and later development of partial small bowel obstruction. INTERVENTIONS: Considering his symptoms we had a suspicion of small bowel pathology for which he underwent an esophagogastroduodenoscopywith biopsies that revealed strongyloidosis as the cause of his symptoms. He was also found to have human T-cell lymphotropic virus infection, likely contributing to the disseminated disease. OUTCOMES: He was started on ivermectin with complete resolution of symptoms and improvement of hyponatremia. LESSONS: It is very important to suspect Strongyloides infection in a patient presenting with syndrome ofinappropriate antidiuretic secretion as hyperinfection and disseminated disease can be life threatening without antihelmintic therapy.

Secondary Syphilis With Hepatitis and Nephrotic Syndrome: A Rare Concurrence.

Syphilis, a chronic multisystem disease, is caused by a spirochete, Treponema pallidum. Clinical presentation may expand to several stages including primary, secondary and latent syphilis, which may present as early or late syphilis. Nephrotic syndrome and acute hepatitis are well-known complications of secondary syphilis. To the best of our knowledge, secondary syphilis with coexisting renal and hepatic complications has rarely been reported. Here we present a rare case of concurrent nephrotic syndrome and acute hepatitis in a patient with secondary syphilis.

Cytomegalovirus related fatal duodenal diverticular bleeding: Case report and literature review.

Involvement of gastrointestinal tract by cytomegalovirus (CMV) is common. CMV infections mainly run their course without any clinical signs in immunocompetent hosts. In contrast, CMV can cause severe infections with serious consequences in a immunocompromised state typically associated with organ transplants, highly immunosuppressive cancer chemotherapy, advanced HIV infection or treatment with corticosteroids. The incidence and severity of these manifestations of CMV is directly proportional with the degree of cellular immune dysfunction, i.e., CD8+ Cytotoxic T-cell response. Clinical manifestations of CMV can become apparent in different situations including reactivation of CMV from latency, primary infection in a seronegative host, or exposure of a seropositive host to a new strain of CMV. As the clinical signs of CMV in immunodeficient patients are usually sparse, physicians should be highly vigilant about CMV infection, a treatable condition that otherwise is associated with significant mortality. Here we report a rare case of severe gastrointestinal CMV infection with sustained immunodeficiency secondary to treatment with steroids manifesting as fatal duodenal diverticular bleeding.