Letters to the Editor 1130-0108/2013/105/1/56-57 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS Copyright © 2013 ARÁN EDICIONES, S. L. REV ESP ENFERM DIG (Madrid) Vol. 105, N.° 1, pp. 56-57, 2013 Infectious esophagic fistula: A common virus with an extraordinary presentation Key words: Cytomegalovirus. Fistula. Elderly. Immunosuppres- sion. Corticosteroids. Valganciclovir. Dear Editor, Cytomegalovirus (CMV) is an herpesvirinae virus widely spread thorough general population, with a global prevalence between 40-100%. After primo-infection, the virus remains in latent phase and can reactivate under immunosuppression situa- tions from different etiologies, like drug therapy -immunosup- pressants (1), chemotherapy (2)- or immunodeficiencies -primary or acquired (3,4)-. CMV is a known opportunistic pathogen of the gastrointestinal tract and can cause a wide spectrum of lesions in esophagus, stomach and bowels (5). Case report We present an 88-year-old woman with polymyalgia rheumatica on treatment with oral corticosteroids (prednisone 30 mg b.i.d) who was admitted to our institution because of dysphagia, odynophagia and fatigue in the last two weeks. Some days before admission, the patient had complained of an episode of atypical thoracic pain irradiated to her neck, with a normal cardiologic study. One day after her admission she pre- sented with hematemesis without hemodynamic instability or anemia. An upper endoscopy was performed, showing a par- tially fibrin-covered orifice with an apparently blind end, locat- ed in the cervical esophagus (Fig. 1A). Biopsies from the orifice borders were taken. An esophagogram and a computerized tomography scan were performed (Fig. 1B and C), showing a fistula in the lateral face of the cervical esophagus, in commu- nication with a pseudo-cavity filled with oral contrast (esoph- agogram). The biopsies demonstrated the presence of the char- acteristic cytopathic CMV effect (Fig. 1D). After diagnosis of Fig. 1. A. Endoscopic image of cervical esophagus showing the fistula entrance. B. Cervical computed tomography scan: esophagic fistula in the lateral left side (red arrow). C. Barium study that demonstrates filling of the esophagic fistula (red arrow). D. Histological examination of esophagic mucosa with cytomegalic inclusions in the fistulous tract (i, red arrows) (HEX400). These inclusions expressed immunopositivity for anti- CMV monoclonal antibody (ii, red arrows).