SUN-451 - Cytomegalovirus Gastritis Associated with Long - Term Physiologic Glucocorticoid Replacement in Primary Adrenal Insufficiency

Background:
Cytomegalovirus (CMV) gastrointestinal disease predominately affects individuals with compromised cell mediated immunity, including HIV infection, malignancy, or solid organ transplantation. Gastric involvement is uncommon and frequently underrecognized due to nonspecific clinical presentations. The occurrence of CMV gastritis in patients with primary adrenal insufficiency receiving chronic glucocorticoid replacement has been rarely reported and remains poorly characterized.

Case Presentation:
We report the case of a 72-year-old woman with primary adrenal insufficiency who had been receiving glucocorticoid replacement therapy for past four years, along with a history of coronary artery disease, deep vein thrombosis, and hypothyroidism, who presented with 3 month history of progressive epigastric pain with a negative Helicobacter pylori urea breath test and failure of symptom resolution despite proton pump inhibitor therapy. Esophagogastroduodenoscopy revealed esophageal plaques consistent with candidiasis, a Hill grade IV gastroesophageal flap valve, and erosive nodular chronic gastritis with hemorrhage. Gastric biopsies demonstrated characteristic cytomegalovirus (CMV) inclusion bodies, confirming CMV gastritis. An extensive evaluation did not identify alternative causes of immunosuppression, including HIV infection, malignancy, organ transplantation, chemotherapy, or exposure to other immunosuppressive therapies.

The patient was initially treated with oral antiviral therapy but was unable to tolerate oral intake, necessitating hospitalization and initiation of intravenous ganciclovir. Her clinical course was complicated by persistent nausea and recurrent hospitalizations, ultimately requiring placement of a peripherally inserted central catheter for a six-week course of intravenous ganciclovir. In the absence of other identifiable risk factors, chronic glucocorticoid use–associated CMV gastritis was considered the most likely diagnosis.

Discussion:
This case highlights a potentially underrecognized susceptibility to opportunistic infection in patients with adrenal insufficiency receiving long-term physiologic glucocorticoid replacement. Although replacement dosing is intended to approximate endogenous cortisol secretion and is generally considered immunologically neutral, chronic exposure, particularly in older adults may impair cell-mediated immunity and predispose to infections. Clinicians should maintain a high index of suspicion for opportunistic infections in patients with chronic adrenal insufficiency who present with refractory gastrointestinal symptoms. As early recognition may prevent delayed diagnosis, prolonged morbidity, and recurrent hospitalizations.

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