cytomegalovirus ( cmv ) infections are commonly reported in severely immunocompromized patients , including those with acquired immunodeficiency syndrome and patients who have received immunosuppressive therapy after transplantation or chemotherapy for malignant disease . cmv is a ubiquitous member of the herpes virus family and is a dna virus . the alimentary tract is the target organ of cmv infection , which may affect the gastrointestinal tract anywhere from the mouth to the anus . the most commonly affected site is the colon , followed by the duodenum , stomach , esophagus and small intestine . esophagitis , gastritis , duodenitis and enterocolitis are induced by cmv infection in the gastrointestinal tract . many reports show that cmv infection can cause colitis , ulcers , and , very rarely , pseudopolyps , pseudomembranes and even mass lesions . the most common manifestations of cmv colitis are diarrhea , fever , gastrointestinal bleeding and abdominal pain . we report a case of massive upper and lower gastrointestinal bleeding due to cmv - related duodenal and colonic ulcers in an elderly patient treated for non - hodgkin lymphoma . an 82-year - old turkish woman was admitted to the emergency department for widespread abdominal pain , diffuse arthralgia , dyspnea and weakness in the upper and lower limbs . she was treated with immunosuppressive drugs for non - hodgkin lymphoma ( diffuse b - cell lymphoma ) six months beforehand . according to the protocol for non - hodgkin lymphoma , she was given a course of systemic chemotherapy consisting of rituximab , cyclophosphamide , doxorubicin and vincristine . additionally , she was chronically treated for parkinson disease , diabetes mellitus , hypertension and hypercholesterolemia . her pain was resistant to painkillers , including non - steroid anti - inflammatory drugs and morphine derivatives . initial physical examination revealed mild abdominal discomfort , anorexia , nausea and absence of fever . an examination of the abdomen revealed mild direct tenderness of the epigastrium and the right periumbilical area , but no masses or organomegaly . routine laboratory investigations revealed : hemoglobin 9.24 g / dl , leukocyte count 18,800/mm , platelet count 128,000/mm , c - reactive protein level 38 mg / dl , international normalized ratio 1.4 , protein level 6.1 g / dl , albumin level 2.8 g / dl . abdominal computerized tomography showed significant thickening of the wall of the first part of the duodenum , with infiltration of the locoregional fat . since vital signs were stable , we decided not to perform any urgent endoscopic examinations . at day 9 of hospitalization , the patient was transferred to the intensive care unit due to a high risk for major gastrointestinal bleeding . esophagogastroduodenoscopy was performed and revealed a deep 3 cm - diameter ulcer with blood clots , without fresh blood in the first portion of the duodenum . three hours after the gastroscopy , the patient still had a low arterial blood pressure ( 70/45 mmhg ) , and her hemoglobin concentration decreased to 6.2 g / dl . up to 4 hours before surgical exploration , a total of 8 pints of packed red blood cells were transfused . on exploration , intraluminal blood since the endoscopy showed fresh bleeding from the ulcer , localized in the first part of the duodenum , a distal gastrectomy was performed . the source - origin of the lower intestinal bleeding could not be precisely evaluated by simultaneous colonoscopy , and the patient underwent total colectomy with end ileostomy . histological examination of the resected specimen showed focal areas of mucosal ulceration , with an underlying chronic inflammatory infiltrate ( figure 1 ) . scattered cytomegalic cells were present , with a characteristic owl s eye pattern of intranuclear inclusion , surrounded by a clear halo and a smaller granular cytoplasmic inclusions . immunostaining for cmv was positive for the cytomegalic cells both in the duodenum and in the colon ( figure 2 ) . after the pathological diagnosis , cmv polymerase chain reaction on blood was performed and it resulted weakly positive ( 2000 copies / ml in whole blood ; qiagen symphony quantitative real - time pcr , qiagen sample & assay technologies , germany).during the post - operative period , the patient was stable and exhibited a hemoglobin level of 10.2 g / dl with no need of further blood transfusions . because of the severe respiratory distress related to cmv pneumonia , the patient continued to stay in the intensive care unit . ganciclovir ( 2200 mg / day ) was given intravenously to treat the cmv disease . the tough ache complaints ( such as arthralgia or epigastric pain ) that were resistant to traditional painkillers ( non - steroid anti - inflammatory drugs and morphine derivatives ) , dissolved particularly after ganciclovir treatment . on day 16 , the patient died from cardiorespiratory complications . this is due to the increasing number of immunosuppressive medications , intensive cancer chemotherapy use , recurrent transplantations , progressively aging population , and the higher number of human immunodeficiency virus infections . cmv infection often develops latently , after acute infection , with no evidence of signs or symptoms . this disease is often diagnosed thanks to a pathologic and serologic examination , since the clinical symptoms are not specific . the symptoms of cmv in the alimentary tract can range from mild anorexia to obvious hemorrhage and perforation . this virus can infect any part of the gastrointestinal tract , from the mouth to the anus , with the colon being the most commonly affected organ , and the stomach and small bowel being relatively affected . additionally , the sigmoid colon and the rectum are the most affected portions of colon . the antrum is the most common site affected by cmv in the upper gastrointestinal tract . the clinical presentation of cmv disease in the gastrointestinal tract is multiple , with symptoms such as odynophagia , hematemesis , dyspepsia - like symptoms , diarrhea , rectal bleeding and even intestinal perforation . however , cmv may also rarely involve the duodenum , causing duodenitis and presenting with upper gastrointestinal bleeding . the present case describes the first cmv infection of both duodenum and colon , simultaneously presenting with bleeding . it is difficult to recognize the cmv infection of the gastrointestinal tract , however , it can be suspected in febrile immunocompromized patients with gastrointestinal signs and symptoms . the endoscopic features are relatively variable and may include macroscopically normal mucosa , diffuse erythema , nodules , pseudotumors , erosions and ulcers . cmv infection can not be initially demonstrated on gastrointestinal biopsies , but it can be exactly diagnosed using the specimens collected during surgery . since the virus is located in deep tissue , biopsies should be performed deeply enough to obtain endothelial cells and fibroblasts within the lamina propria . the owl s eye pattern is the hallmark of cmv infection in microscopic evaluation ; however , classical intranuclear inclusions are not always found because cmv may infect the vascular endothelium or the stromal cells under ulcers as well as the mucosal epithelium . serology , on the other side , is not sufficient to diagnose the disease . of note , as a limitation of our case report , cmv molecular biology was not performed ; however , histopathological changes suggestive for cmv infection were detected only in the surgical specimen and not in the specimen taken during endoscopy . in the present case , the initial complaints of our patient were widespread abdominal pain , diffuse arthralgia and weakness in the upper and lower limbs . after microscopic evaluation of a specimen , hypertrophy was detected in nerve cells , justifying the intense pain complained by our patient . meyer et al . reported neural hyperplasia in cmv infection likely due to cmv inclusions and acute inflammatory changes . another important point in our report was the improvement in pain symptoms following ganciclovir treatment , likely related to recovery of neural hyperplasia . systemic antiviral treatment has resulted in dramatically improved outcomes , and the treatment time usually ranges from 1 to 4 weeks . the gastrointestinal complications of cmv infection , which include massive hemorrhage , toxic megacolon , perforation and stenosis , necessitate surgical resection . due to the high risk of complications and mortality from cmv infection in the elderly , all older patients must be offered antiviral treatment as soon as possible . in our case , delay in diagnosis and treatment onset were strongly associated with the fatal outcome . most gastrointestinal cmv infections respond well to ganciclovir treatment , independently from the cause of the underlying immunosuppression . early diagnosis of suspected cmc infection in immunosuppressed patients with gastrointestinal symptoms is of the utmost importance . it should not be forgotten that delayed diagnosis and treatment might increase the morbidity and mortality from cmv infection with major gastrointestinal bleeding .