Massive Hematochezia Due to Acute Hemorrhagic Rectal Ulcer in a Patient with Myasthenia Gravis

A 48-year-old lady with a recent surgery for mediastinal thymoma presented with an acute myasthenic crisis. She was admitted to the intensive care unit with respiratory distress. She was on intravenous immunoglobulin, broad-spectrum antibiotics, blood transfusion, total parenteral nutrition, and an intercostal drain for massive pleural effusion. She developed sudden, painless, clinically significant hematochezia. Sigmoidoscopy showed multiple, geographical ulcers in the distal rectum, just proximal to the dentate line, with active bleeding from a vessel ([Fig. 1]). Bleeding was controlled with mechanical clip placement ([Fig. 2]), and a biopsy was taken from the ulcer margin. The biopsy showed a lot of necrotic material, neutrophils, and vascular thrombi in the lamina propria, acute inflammatory changes with no granulomas, inclusions, or evidence of chronicity. Stool and blood culture were negative. A diagnosis of acute hemorrhagic rectal ulcer (AHRU) was made. She had three more bleeding episodes requiring repeated mechanical clipping at different sites. Proper nutrition was established with intravenous albumin and tube feeding. She developed clinical jaundice with derangement of liver function tests along with pancytopenia. Repeat endoscopic biopsies from the rectal ulcers and base revealed cytomegalovirus (CMV) colitis ([Figs 3] and [4]). CMV deoxyribonucleic acid (DNA) level was 18400 IU/mL in blood. The patient was treated with injectable ganciclovir, after which bleeding stopped, and liver function tests and pancytopenia improved. Weekly CMV DNA levels showed a significant decline. After 3 months, the rectum was clear of ulcers. A rare diagnosis of AHRU complicated with CMV infection was made, which was successfully treated with antivirals, adequate nutritional supplementation, and supportive care.

Fig. 1 Colonoscopic image showing a large geographical ulcer in the distal rectum with active bleeding from a vessel (blue arrow).

Fig. 2 Colonoscopic image in a retroflexed view of the large rectal ulcers with a mechanical clip (blue arrow) that was placed at the site of hemorrhage.

Fig. 3 Colon biopsy showing large cells with viral cytopathic effect in the form of enlarged nuclei with dense basophilic intranuclear inclusions surrounded by a clear halo, owl's eye appearance (blue arrow), typical of cytomegalovirus colitis (hematoxylin and eosin [H&E], ×200).

Fig. 4 Immunocytochemistry for cytomegalovirus (CMV) antigen demonstrating nuclear positivity in infected cells (blue arrow) within inflamed colonic mucosa (CMV immunohistochemistry [IHC], ×200).

Publication History

Article published online:
14 October 2025

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