{"paper_id":"33fdc1b7-5dec-4e70-8a90-51fe936d449f","body_text":"Cytomegalovirus enteritis in a patient with AKI after type B aortic dissection surgery: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Cytomegalovirus enteritis in a patient with AKI after type B aortic dissection surgery: A case report Tongkai Ge, Junqiang Qiu, Zhenzhong Wang, Heng Zuo, Kan Zhou, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8327970/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background Cytomegalovirus (CMV) enteritis is an uncommon clinical entity that frequently predisposes to severe complications, such as gastrointestinal (GI) hemorrhage and perforation, and is associated with substantial mortality. Case Presentation We herein present the management of a case of CMV enteritis in an immunocompetent patient. The patient had a prior history of abdominal aortic replacement and bypass surgery for a type B aortic dissection, following which he developed acute kidney injury (AKI) stage 3 according to KDIGO guidelines. Approximately five weeks after the operation, he presented with massive gastrointestinal hemorrhage and was subsequently diagnosed with CMV enteritis. Treatment included exploratory laparotomy and antiviral therapy with ganciclovir, culminating in a successful recovery. Conclusion This case highlights the potential occurrence of CMV enteritis in individuals conventionally regarded as immunocompetent. Computed tomography (CT) plays a pivotal role in the early diagnosis of small bowel bleeding. Moreover, prompt surgical intervention constitutes an effective therapeutic strategy for hemorrhage control in this clinical scenario. Cytomegalovirus enteritis Obscure gastrointestinal bleed Acute kidney injury Type B aortic dissection Figures Figure 1 Figure 2 Figure 3 Background The incidence of cytomegalovirus (CMV) infection among immunocompromised intensive care unit (ICU) patients ranges from 3.4% to 62.1%, and CMV infection or disease has been identified as an independent risk factor for in-hospital mortality ( 1 ). Colitis represents the most frequent clinical manifestation of gastrointestinal CMV disease, whereas surgical intervention is more commonly required in cases of GI perforation and hemorrhage secondary to CMV enteritis ( 2 , 3 ). Reported in-hospital and overall mortality rates for CMV enteritis are 27.8% and 38.9%, respectively ( 4 ). We herein report a case who accepted exploratory laparotomy and antiviral treatments because of massive hemorrhage associated of CMV enteritis and was successfully discharged. Case description A 62-year-old man presented to our hospital on May 2, 2025, for management of a descending aortic dissection (originating at the T12 level with a tear width of approximately 14 mm). His medical history included a prior aortic dissection extending from the left common carotid artery ostium to the superior mesenteric artery, for which he underwent endovascular stent grafting (XJZDMZ3434200, Medtronic®) distal to the left subclavian artery in October 2024. The current admission was prompted by a Type B aortic dissection (TBAD). Physical examination on admission revealed a blood pressure of 120–130/70–80 mmHg, a pulse rate of 60–80 beats/min, a body weight of 64 kg, and a height of 178 cm. Preoperative laboratory parameters were within normal limits, and his comorbidities were limited to hypertension and atrial fibrillation. On May 8, an interventional procedure was performed by the cardiology team. Intraoperative imaging identified an ulcer in the distal thoracic aorta, adjacent to the celiac trunk. During the attempt to deploy a VALIANT 3434200 (Medtronic®) stent, incomplete deployment occurred, and the device could not be retrieved. Consequently, emergency open surgical repair was undertaken by cardiac surgeons, consisting of abdominal aortic replacement (Terumo®) and a bypass from the aortic graft to the celiac trunk, bilateral renal arteries, and superior mesenteric artery. The procedure was performed off-pump, with a total cardiopulmonary bypass time of 243 minutes. Approximately 20 hours postoperatively, neurological assessment revealed paraplegia, with muscle strength graded MRC 0/5 in the lower limbs and hypoesthesia below the L5 level. Lumbar puncture and subsequent cisternal drainage were performed, demonstrating an opening cerebrospinal fluid pressure of 210 mmH 2 O; no neurological improvement was observed thereafter. On postoperative day (POD) 1, the patient’s serum creatinine level rose to 291.96 µmol/L, and urine output dropped to 10 ml/hour for three consecutive hours, progressing to anuria. A diagnosis of Acute Kidney Injury Stage 3 was established according to KDIGO guidelines. Continuous venovenous hemofiltration (CVVH) was initiated under nephrology guidance. Throughout CVVH, peak and trough serum creatinine levels were 742.83 µmol/L and 311.55 µmol/L, respectively. Urine output recovered to 730 mL (> 0.3 mL/kg/h) on POD 25 and 800 mL (> 0.5 mL/kg/h) on POD 26. Anticoagulation with low molecular weight heparin was started at 0.3 mL twice daily from POD 18 and increased to 0.6 mL twice daily on POD 25. On POD 27, the patient was transferred to another hospital for CVVH twice per week. On POD 38, he developed recurrent hematochezia and was transferred back to our hospital on POD 39. Laboratory studies revealed severe anemia, with hemoglobin (Hb) level of 35 g/L and red blood cell (RBC) count of 1.18×10¹²/L, accompanied by elevated serum creatinine (455 µmol/L) and prolonged activated partial thromboplastin time (APTT, 48.9 s). Contrast-enhanced abdominal CT demonstrated active small bowel bleeding (Fig. 1 ). A multidisciplinary team (MDT) was convened, including gastrointestinal surgeons, interventional radiologists, and gastroenterologists. On POD 40, digital subtraction angiography (DSA) of the celiac artery was performed by an interventional radiologist, which showed no evidence of contrast extravasation (Supplement 1). Despite transfusion of 8 units of cryoprecipitate, 1 unit of platelets, 600 mL of fresh frozen plasma, and 7 units of RBCs, laboratory parameters remained critically deranged, with Hb 30 g/L, RBC count 0.93×10¹²/L, and APTT 54.8 s. Given the persistence of suspected small bowel bleeding, an emergency exploratory laparotomy was performed. Intraoperative examination revealed marked wall thickening of the ileum, approximately 110 cm proximal to the ileocecal valve. Upon enterotomy, a large volume of clotted blood was evacuated, and an actively bleeding mucosal lesion was identified and oversewn with 3 − 0 Vicryl® sutures for hemostasis (Fig. 2 A- 2 B). Capsule endoscopy (CE) was then introduced through the enterotomy site, which showed no additional mucosal lesions or bleeding sources. The affected ileal segment was resected and sent for histopathological evaluation.On the same day, the patient received 10 units of cryoprecipitate, 1 unit of platelets, 600 mL of fresh frozen plasma, and 10 units of RBCs. Subsequent laboratory testing showed Hb 49 g/L, RBC count 1.54×10¹²/L, APTT 46.1 s, and creatinine 413.26 µmol/L. On POD 47, histopathological examination of the resected specimen showed complete loss of ileal villous architecture, and immunohistochemistry (IHC) was positive for CMV (Fig. 3 A- 3 B). Accordingly, the MDT recommended initiation of ganciclovir, with dosing adjusted according to renal function. On POD 47, the patient received 2.5 mg/kg of ganciclovir, with a serum creatinine level of 159.48 µmol/L. By POD 52, the creatinine had improved to 88.67 µmol/L, and the ganciclovir dose was increased to 4.5 mg/kg. The patient’s condition stabilized, and he was discharged from our center on POD 54. Discussion Cytomegalovirus (CMV) can be detected in both immunocompetent and immunocompromised individuals; however, symptomatic CMV disease occurs more frequently in immunocompromised hosts. A standardized quantitative definition of immunocompromised status remains lacking. Previous studies have commonly defined immunocompromised patients as those with AIDS, solid organ transplantation, and/or exposure to chemotherapy, systemic corticosteroids, or other immunosuppressive agents( 5 ). Notably, identified risk factors for CMV enteritis and colitis include chronic kidney disease and elevated serum creatinine levels( 4 , 6 ). Acute kidney injury (AKI) is a frequent complication following Type B aortic dissection (TBAD), with reported incidences of stage 3 AKI and renal replacement therapy reaching 25.8% and 6.1%, respectively( 7 ). Importantly, renal impairment can induce T-cell exhaustion and dysfunction, leading to dysregulated immune homeostasis and diminished pathogen clearance( 8 ). Therefore, patients with AKI may exist in a state of “relative immunocompromise”, potentially facilitating the progression from latent CMV infection to active clinical disease. The clinical manifestations of CMV enteritis are often non-specific. In the present case, the patient presented with hematochezia, necessitating accurate localization of the bleeding source. In scenarios of obscure gastrointestinal bleeding, we initially performed contrast-enhanced computed tomography (CT), which identified active small bowel bleeding. Subsequent celiac arteriography failed to demonstrate a culprit vessel. This aligns with evidence reported by Kulkarni C et al., indicating that multidetector computed tomography (MDCT) exhibits superior sensitivity to digital subtraction angiography and capsule endoscopy (CE) in localizing small bowel bleeding( 9 ). Since its introduction in 2000, CE has become an important diagnostic modality for obscure gastrointestinal bleeding( 10 ). Its accuracy is well established, and its intraoperative application—as utilized in this case—can offer real-time guidance superior to preoperative imaging alone. Beyond localization of bleeding, determining its underlying etiology is critical. In our patient, the diagnosis of CMV enteritis was confirmed by immunohistochemistry (IHC) on postoperative day 8 following the onset of hematochezia—a significantly shorter interval than previously reported( 3 , 11 ). Antiviral therapy with ganciclovir was initiated immediately upon diagnosis. Ganciclovir represents first-line treatment for CMV infection in patients with inflammatory bowel disease or organ transplantation( 12 , 13 ). Prior evidence suggests that a combined intravenous (IV) and oral (PO) antiviral regimen may yield superior outcomes compared to IV or PO monotherapy in both immunocompromised and immunocompetent patients with gastrointestinal CMV disease( 14 ). However, given the known nephrotoxicity of ganciclovir, we administered IV therapy only, initiating at a reduced dose of 2.5 mg/kg and escalating to 4.5 mg/kg upon normalization of renal function. Conclusions For patients with a history of AKI who exhibit GI symptoms, we need to be alert to the possibility of rare microbial infections. CMV enteritis can occur in people with normal immunity and cause gastrointestinal bleeding, and surgical surgery can be performed to stop bleeding if necessary, and antiviral therapy is also an important treatment method. Abbreviations Cytomegalovirus (CMV) Intensive care unit (ICU) Gastrointestinal (GI) Postoperative day (POD) Acute kidney injury (AKI) Activated partial thromboplastin time (APTT) Red blood cells (RBC) Capsule endoscopy (CE) Multidisciplinary team (MDT) Immunohistochemistry (IHC) Type B aortic dissection (TBAD) Intravenous (IV) Per os (PO) Declarations Ethics approval and consent to participate: The study involving the human participant was reviewed and approved by the Ethics Committee of Guangdong Provincial People’s Hospital (KY2025-1105-01). Informed consent for participation was obtained from the patient involved in the study. Consent for publication: Written informed consent was obtained from the patient (or the patient’s parent/legal guardian) for publication of this case report and any accompanying images/data. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This research was funded by Noncommunicable Chronic Diseases-National Science and Technology Major Project of China (grant number: 2023ZD0504403) , Natural Science Foundation of China (grant number: 82370473), and Guangdong Provincial Medical Science and Technology Research Fund Project (grant number: A2022433). Author s’ c ontributions: Tongkai Ge and Junqiang Qiu were responsible for drafting the article. Zhenzhong Wang , Heng Zuo , and Kan Zhou were responsible for collecting data. Changjiang Yu and Tucheng Sun were responsible for the implementation of cardiac surgery. Huanlei Huang was responsible for revising the manuscript. Yingkai Xiao was responsible for the conceptualization and m ethodology. All authors read and approved the final manuscript. Acknowledgments: Not applicable. References Fernández S, Castro P, Azoulay E. What intensivists need to know about cytomegalovirus infection in immunocompromised ICU patients. Intensive Care Med (2025) 51:39–61. doi: 10.1007/s00134-024-07737-5 Fisher AT, Bessoff KE, Nicholas V, Badger J, Knowlton L, Forrester JD. Fatal Case of Perforated Cytomegalovirus Colitis: Case Report and Systematic Review. Surg Infect (Larchmt) (2022) 23:127–134. doi: 10.1089/sur.2021.173 Kim S, Yoon KW, Gil E, Yoo K, Choi KJ, Park C-M. Emergency gastrointestinal tract operation associated with cytomegalovirus infection. Ann Surg Treat Res (2023) 104:119–125. doi: 10.4174/astr.2023.104.2.119 Yeh P-J, Chiu C-T, Lai M-W, Wu R-C, Chen C-M, Kuo C-J, Hsu J-T, Su M-Y, Lin W-P, Chen T-H, et al. Clinical manifestations, risk factors, and prognostic factors of cytomegalovirus enteritis. Gut Pathog (2021) 13:53. doi: 10.1186/s13099-021-00450-4 Chaemsupaphan T, Limsrivilai J, Thongdee C, Sudcharoen A, Pongpaibul A, Pausawasdi N, Charatcharoenwitthaya P. Patient characteristics, clinical manifestations, prognosis, and factors associated with gastrointestinal cytomegalovirus infection in immunocompetent patients. BMC Gastroenterol (2020) 20:22. doi: 10.1186/s12876-020-1174-y Soni K, Puing A. Cytomegalovirus Colitis in Adult Patients with Inflammatory Bowel Disease. Viruses (2025) 17:752. doi: 10.3390/v17060752 Musajee M, Katsogridakis E, Kiberu Y, Banerjee C, George R, Modarai B, Saratzis A, Sandford B. Acute Kidney Injury in Patients with Acute Type B Aortic Dissection. Eur J Vasc Endovasc Surg (2023) 65:256–262. doi: 10.1016/j.ejvs.2022.10.032 Yeh P-J, Wu R-C, Chen C-M, Chiu C-T, Lai M-W, Chen C-C, Kuo C-J, Hsu J-T, Su M-Y, Le P-H. Risk Factors, Clinical and Endoscopic Features, and Clinical Outcomes in Patients with Cytomegalovirus Esophagitis. J Clin Med (2022) 11:1583. doi: 10.3390/jcm11061583 Kulkarni C, Moorthy S, Sreekumar K, Rajeshkannan R, Nazar P, Sandya C, Sivasubramanian S, Ramchandran P. In the workup of patients with obscure gastrointestinal bleed, does 64-slice MDCT have a role? Indian J Radiol Imaging (2012) 22:47–53. doi: 10.4103/0971-3026.95404 Ghoshal UC, Roy A, Goenka MK. Capsule endoscopy for small bowel bleed: Current update. Indian J Gastroenterol (2024) 43:896–904. doi: 10.1007/s12664-024-01637-8 Yeh P-J, Wu R-C, Tsou Y-K, Chen C-M, Chiu C-T, Chen C-C, Lai M-W, Pan Y-B, Le P-H. Comparative Analysis of Cytomegalovirus Gastrointestinal Disease in Immunocompetent and Immunocompromised Patients. Viruses (2024) 16:452. doi: 10.3390/v16030452 Hsieh C-R, Wu R-C, Kuo C-J, Yeh P-J, Yeh Y-M, Chen C-L, Chiu C-T, Chiu C-H, Pan Y-B, Tsou Y-K, et al. Adequate antiviral treatment lowers overall complications of cytomegalovirus colitis among inpatients with inflammatory bowel diseases. BMC Infect Dis (2024) 24:443. doi: 10.1186/s12879-024-09317-w Walti CS, Khanna N, Avery RK, Helanterä I. New Treatment Options for Refractory/Resistant CMV Infection. Transpl Int (2023) 36:11785. doi: 10.3389/ti.2023.11785 Yeh P-J, Wu R-C, Chiu C-T, Lai M-W, Chen C-M, Pan Y-B, Su M-Y, Kuo C-J, Lin W-R, Le P-H. Cytomegalovirus Diseases of the Gastrointestinal Tract. Viruses (2022) 14:352. doi: 10.3390/v14020352 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 02 Feb, 2026 Reviews received at journal 13 Jan, 2026 Reviews received at journal 05 Jan, 2026 Reviewers agreed at journal 05 Jan, 2026 Reviewers agreed at journal 03 Jan, 2026 Reviewers invited by journal 24 Dec, 2025 Editor assigned by journal 23 Dec, 2025 Editor invited by journal 22 Dec, 2025 Submission checks completed at journal 20 Dec, 2025 First submitted to journal 20 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8327970\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":565163848,\"identity\":\"5f449262-6853-4d97-96f7-d114d31e49cc\",\"order_by\":0,\"name\":\"Tongkai Ge\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical 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09:33:48\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":128582,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eis the image of abdominal contrast-enhanced CT. Red arrow pointed the small bowel bleeding.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8327970/v1/6b611a390005c70fcd9d300b.png\"},{\"id\":99220066,\"identity\":\"d57ca75b-4b54-465c-8a41-d633dbfd0e26\",\"added_by\":\"auto\",\"created_at\":\"2025-12-30 09:33:48\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":357483,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eA-B showed the resected ileum.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8327970/v1/dcd57d49118a48504f2e76d4.png\"},{\"id\":99317152,\"identity\":\"c5c529e2-c6e2-4ee9-8398-84c12491988f\",\"added_by\":\"auto\",\"created_at\":\"2025-12-31 16:29:42\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":450424,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eA-B are the images of pathological examination. They indicated the most of the villous structure of the small intestine disappeared with inflammatory exudation and much inflammatory cell infiltration in the stroma.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8327970/v1/1d630cc887ed9d5d78eddb5f.png\"},{\"id\":99788101,\"identity\":\"d76613cd-24f4-46a5-8d93-71469b3a32e3\",\"added_by\":\"auto\",\"created_at\":\"2026-01-08 12:44:41\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1457545,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8327970/v1/f7dd20f4-3a1d-462a-b052-a98a1b3dd747.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Cytomegalovirus enteritis in a patient with AKI after type B aortic dissection surgery: A case report\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eThe incidence of cytomegalovirus (CMV) infection among immunocompromised intensive care unit (ICU) patients ranges from 3.4% to 62.1%, and CMV infection or disease has been identified as an independent risk factor for in-hospital mortality (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). Colitis represents the most frequent clinical manifestation of gastrointestinal CMV disease, whereas surgical intervention is more commonly required in cases of GI perforation and hemorrhage secondary to CMV enteritis (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). Reported in-hospital and overall mortality rates for CMV enteritis are 27.8% and 38.9%, respectively (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). We herein report a case who accepted exploratory laparotomy and antiviral treatments because of massive hemorrhage associated of CMV enteritis and was successfully discharged.\\u003c/p\\u003e\"},{\"header\":\"Case description\",\"content\":\"\\u003cp\\u003eA 62-year-old man presented to our hospital on May 2, 2025, for management of a descending aortic dissection (originating at the T12 level with a tear width of approximately 14 mm). His medical history included a prior aortic dissection extending from the left common carotid artery ostium to the superior mesenteric artery, for which he underwent endovascular stent grafting (XJZDMZ3434200, Medtronic\\u0026reg;) distal to the left subclavian artery in October 2024. The current admission was prompted by a Type B aortic dissection (TBAD). Physical examination on admission revealed a blood pressure of 120\\u0026ndash;130/70\\u0026ndash;80 mmHg, a pulse rate of 60\\u0026ndash;80 beats/min, a body weight of 64 kg, and a height of 178 cm. Preoperative laboratory parameters were within normal limits, and his comorbidities were limited to hypertension and atrial fibrillation.\\u003c/p\\u003e \\u003cp\\u003eOn May 8, an interventional procedure was performed by the cardiology team. Intraoperative imaging identified an ulcer in the distal thoracic aorta, adjacent to the celiac trunk. During the attempt to deploy a VALIANT 3434200 (Medtronic\\u0026reg;) stent, incomplete deployment occurred, and the device could not be retrieved. Consequently, emergency open surgical repair was undertaken by cardiac surgeons, consisting of abdominal aortic replacement (Terumo\\u0026reg;) and a bypass from the aortic graft to the celiac trunk, bilateral renal arteries, and superior mesenteric artery. The procedure was performed off-pump, with a total cardiopulmonary bypass time of 243 minutes.\\u003c/p\\u003e \\u003cp\\u003eApproximately 20 hours postoperatively, neurological assessment revealed paraplegia, with muscle strength graded MRC 0/5 in the lower limbs and hypoesthesia below the L5 level. Lumbar puncture and subsequent cisternal drainage were performed, demonstrating an opening cerebrospinal fluid pressure of 210 mmH\\u003csub\\u003e2\\u003c/sub\\u003eO; no neurological improvement was observed thereafter.\\u003c/p\\u003e \\u003cp\\u003eOn postoperative day (POD) 1, the patient\\u0026rsquo;s serum creatinine level rose to 291.96 \\u0026micro;mol/L, and urine output dropped to 10 ml/hour for three consecutive hours, progressing to anuria. A diagnosis of Acute Kidney Injury Stage 3 was established according to KDIGO guidelines. Continuous venovenous hemofiltration (CVVH) was initiated under nephrology guidance. Throughout CVVH, peak and trough serum creatinine levels were 742.83 \\u0026micro;mol/L and 311.55 \\u0026micro;mol/L, respectively. Urine output recovered to 730 mL (\\u0026gt;\\u0026thinsp;0.3 mL/kg/h) on POD 25 and 800 mL (\\u0026gt;\\u0026thinsp;0.5 mL/kg/h) on POD 26. Anticoagulation with low molecular weight heparin was started at 0.3 mL twice daily from POD 18 and increased to 0.6 mL twice daily on POD 25.\\u003c/p\\u003e \\u003cp\\u003eOn POD 27, the patient was transferred to another hospital for CVVH twice per week. On POD 38, he developed recurrent hematochezia and was transferred back to our hospital on POD 39. Laboratory studies revealed severe anemia, with hemoglobin (Hb) level of 35 g/L and red blood cell (RBC) count of 1.18\\u0026times;10\\u0026sup1;\\u0026sup2;/L, accompanied by elevated serum creatinine (455 \\u0026micro;mol/L) and prolonged activated partial thromboplastin time (APTT, 48.9 s). Contrast-enhanced abdominal CT demonstrated active small bowel bleeding (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). A multidisciplinary team (MDT) was convened, including gastrointestinal surgeons, interventional radiologists, and gastroenterologists.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eOn POD 40, digital subtraction angiography (DSA) of the celiac artery was performed by an interventional radiologist, which showed no evidence of contrast extravasation (Supplement 1). Despite transfusion of 8 units of cryoprecipitate, 1 unit of platelets, 600 mL of fresh frozen plasma, and 7 units of RBCs, laboratory parameters remained critically deranged, with Hb 30 g/L, RBC count 0.93\\u0026times;10\\u0026sup1;\\u0026sup2;/L, and APTT 54.8 s. Given the persistence of suspected small bowel bleeding, an emergency exploratory laparotomy was performed. Intraoperative examination revealed marked wall thickening of the ileum, approximately 110 cm proximal to the ileocecal valve. Upon enterotomy, a large volume of clotted blood was evacuated, and an actively bleeding mucosal lesion was identified and oversewn with 3\\u0026thinsp;\\u0026minus;\\u0026thinsp;0 Vicryl\\u0026reg; sutures for hemostasis (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003eA-\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003eB). Capsule endoscopy (CE) was then introduced through the enterotomy site, which showed no additional mucosal lesions or bleeding sources. The affected ileal segment was resected and sent for histopathological evaluation.On the same day, the patient received 10 units of cryoprecipitate, 1 unit of platelets, 600 mL of fresh frozen plasma, and 10 units of RBCs. Subsequent laboratory testing showed Hb 49 g/L, RBC count 1.54\\u0026times;10\\u0026sup1;\\u0026sup2;/L, APTT 46.1 s, and creatinine 413.26 \\u0026micro;mol/L.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eOn POD 47, histopathological examination of the resected specimen showed complete loss of ileal villous architecture, and immunohistochemistry (IHC) was positive for CMV (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eA-\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eB). Accordingly, the MDT recommended initiation of ganciclovir, with dosing adjusted according to renal function. On POD 47, the patient received 2.5 mg/kg of ganciclovir, with a serum creatinine level of 159.48 \\u0026micro;mol/L. By POD 52, the creatinine had improved to 88.67 \\u0026micro;mol/L, and the ganciclovir dose was increased to 4.5 mg/kg. The patient\\u0026rsquo;s condition stabilized, and he was discharged from our center on POD 54.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eCytomegalovirus (CMV) can be detected in both immunocompetent and immunocompromised individuals; however, symptomatic CMV disease occurs more frequently in immunocompromised hosts. A standardized quantitative definition of immunocompromised status remains lacking. Previous studies have commonly defined immunocompromised patients as those with AIDS, solid organ transplantation, and/or exposure to chemotherapy, systemic corticosteroids, or other immunosuppressive agents(\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). Notably, identified risk factors for CMV enteritis and colitis include chronic kidney disease and elevated serum creatinine levels(\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). Acute kidney injury (AKI) is a frequent complication following Type B aortic dissection (TBAD), with reported incidences of stage 3 AKI and renal replacement therapy reaching 25.8% and 6.1%, respectively(\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). Importantly, renal impairment can induce T-cell exhaustion and dysfunction, leading to dysregulated immune homeostasis and diminished pathogen clearance(\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e). Therefore, patients with AKI may exist in a state of \\u0026ldquo;relative immunocompromise\\u0026rdquo;, potentially facilitating the progression from latent CMV infection to active clinical disease.\\u003c/p\\u003e \\u003cp\\u003eThe clinical manifestations of CMV enteritis are often non-specific. In the present case, the patient presented with hematochezia, necessitating accurate localization of the bleeding source. In scenarios of obscure gastrointestinal bleeding, we initially performed contrast-enhanced computed tomography (CT), which identified active small bowel bleeding. Subsequent celiac arteriography failed to demonstrate a culprit vessel. This aligns with evidence reported by Kulkarni C et al., indicating that multidetector computed tomography (MDCT) exhibits superior sensitivity to digital subtraction angiography and capsule endoscopy (CE) in localizing small bowel bleeding(\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). Since its introduction in 2000, CE has become an important diagnostic modality for obscure gastrointestinal bleeding(\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Its accuracy is well established, and its intraoperative application\\u0026mdash;as utilized in this case\\u0026mdash;can offer real-time guidance superior to preoperative imaging alone. Beyond localization of bleeding, determining its underlying etiology is critical. In our patient, the diagnosis of CMV enteritis was confirmed by immunohistochemistry (IHC) on postoperative day 8 following the onset of hematochezia\\u0026mdash;a significantly shorter interval than previously reported(\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). Antiviral therapy with ganciclovir was initiated immediately upon diagnosis. Ganciclovir represents first-line treatment for CMV infection in patients with inflammatory bowel disease or organ transplantation(\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). Prior evidence suggests that a combined intravenous (IV) and oral (PO) antiviral regimen may yield superior outcomes compared to IV or PO monotherapy in both immunocompromised and immunocompetent patients with gastrointestinal CMV disease(\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). However, given the known nephrotoxicity of ganciclovir, we administered IV therapy only, initiating at a reduced dose of 2.5 mg/kg and escalating to 4.5 mg/kg upon normalization of renal function.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eFor patients with a history of AKI who exhibit GI symptoms, we need to be alert to the possibility of rare microbial infections. CMV enteritis can occur in people with normal immunity and cause gastrointestinal bleeding, and surgical surgery can be performed to stop bleeding if necessary, and antiviral therapy is also an important treatment method.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eCytomegalovirus (CMV)\\u003c/p\\u003e\\n\\u003cp\\u003eIntensive care unit (ICU)\\u003c/p\\u003e\\n\\u003cp\\u003eGastrointestinal (GI)\\u003c/p\\u003e\\n\\u003cp\\u003ePostoperative day (POD)\\u003c/p\\u003e\\n\\u003cp\\u003eAcute kidney injury (AKI)\\u003c/p\\u003e\\n\\u003cp\\u003eActivated partial thromboplastin time (APTT)\\u003c/p\\u003e\\n\\u003cp\\u003eRed blood cells (RBC)\\u003c/p\\u003e\\n\\u003cp\\u003eCapsule endoscopy (CE)\\u003c/p\\u003e\\n\\u003cp\\u003eMultidisciplinary team (MDT)\\u003c/p\\u003e\\n\\u003cp\\u003eImmunohistochemistry (IHC)\\u003c/p\\u003e\\n\\u003cp\\u003eType B aortic dissection (TBAD)\\u003c/p\\u003e\\n\\u003cp\\u003eIntravenous (IV)\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003ePer os (PO)\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate:\\u003c/strong\\u003e The study involving the human participant was reviewed and approved by the Ethics Committee of Guangdong Provincial People’s Hospital (KY2025-1105-01). Informed consent for participation was obtained from the patient involved in the study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication:\\u0026nbsp;\\u003c/strong\\u003e Written informed consent was obtained from the patient (or the patient’s parent/legal guardian) for publication of this case report and any accompanying images/data.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials:\\u003c/strong\\u003e The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests:\\u003c/strong\\u003e The authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding:\\u003c/strong\\u003eThis research was funded by Noncommunicable Chronic Diseases-National Science and Technology Major Project of China (grant number: 2023ZD0504403) , Natural Science Foundation of China (grant number: 82370473), and Guangdong Provincial Medical Science and Technology Research Fund Project (grant number: A2022433).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor\\u003c/strong\\u003e\\u003cstrong\\u003es’\\u003c/strong\\u003e\\u003cstrong\\u003ec\\u003c/strong\\u003e\\u003cstrong\\u003eontributions:\\u003c/strong\\u003eTongkai Ge and\\u0026nbsp;Junqiang Qiu were responsible for drafting the article. Zhenzhong Wang , Heng Zuo\\u0026nbsp;, and Kan Zhou\\u0026nbsp;were responsible for collecting data. Changjiang Yu and Tucheng Sun were responsible for the implementation of cardiac surgery. Huanlei Huang was responsible for revising the manuscript.\\u0026nbsp;Yingkai Xiao was responsible for the conceptualization and m\\u003cstrong\\u003eethodology.\\u0026nbsp;\\u003c/strong\\u003eAll authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments:\\u003c/strong\\u003e Not applicable.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eFern\\u0026aacute;ndez S, Castro P, Azoulay E. What intensivists need to know about cytomegalovirus infection in immunocompromised ICU patients. \\u003cem\\u003eIntensive Care Med\\u003c/em\\u003e (2025) 51:39\\u0026ndash;61. doi: 10.1007/s00134-024-07737-5\\u003c/li\\u003e\\n\\u003cli\\u003eFisher AT, Bessoff KE, Nicholas V, Badger J, Knowlton L, Forrester JD. Fatal Case of Perforated Cytomegalovirus Colitis: Case Report and Systematic Review. \\u003cem\\u003eSurg Infect (Larchmt)\\u003c/em\\u003e (2022) 23:127\\u0026ndash;134. doi: 10.1089/sur.2021.173\\u003c/li\\u003e\\n\\u003cli\\u003eKim S, Yoon KW, Gil E, Yoo K, Choi KJ, Park C-M. Emergency gastrointestinal tract operation associated with cytomegalovirus infection. \\u003cem\\u003eAnn Surg Treat Res\\u003c/em\\u003e (2023) 104:119\\u0026ndash;125. doi: 10.4174/astr.2023.104.2.119\\u003c/li\\u003e\\n\\u003cli\\u003eYeh P-J, Chiu C-T, Lai M-W, Wu R-C, Chen C-M, Kuo C-J, Hsu J-T, Su M-Y, Lin W-P, Chen T-H, et al. Clinical manifestations, risk factors, and prognostic factors of cytomegalovirus enteritis. \\u003cem\\u003eGut Pathog\\u003c/em\\u003e (2021) 13:53. doi: 10.1186/s13099-021-00450-4\\u003c/li\\u003e\\n\\u003cli\\u003eChaemsupaphan T, Limsrivilai J, Thongdee C, Sudcharoen A, Pongpaibul A, Pausawasdi N, Charatcharoenwitthaya P. Patient characteristics, clinical manifestations, prognosis, and factors associated with gastrointestinal cytomegalovirus infection in immunocompetent patients. \\u003cem\\u003eBMC Gastroenterol\\u003c/em\\u003e (2020) 20:22. doi: 10.1186/s12876-020-1174-y\\u003c/li\\u003e\\n\\u003cli\\u003eSoni K, Puing A. Cytomegalovirus Colitis in Adult Patients with Inflammatory Bowel Disease. \\u003cem\\u003eViruses\\u003c/em\\u003e (2025) 17:752. doi: 10.3390/v17060752\\u003c/li\\u003e\\n\\u003cli\\u003eMusajee M, Katsogridakis E, Kiberu Y, Banerjee C, George R, Modarai B, Saratzis A, Sandford B. Acute Kidney Injury in Patients with Acute Type B Aortic Dissection. \\u003cem\\u003eEur J Vasc Endovasc Surg\\u003c/em\\u003e (2023) 65:256\\u0026ndash;262. doi: 10.1016/j.ejvs.2022.10.032\\u003c/li\\u003e\\n\\u003cli\\u003eYeh P-J, Wu R-C, Chen C-M, Chiu C-T, Lai M-W, Chen C-C, Kuo C-J, Hsu J-T, Su M-Y, Le P-H. Risk Factors, Clinical and Endoscopic Features, and Clinical Outcomes in Patients with Cytomegalovirus Esophagitis. \\u003cem\\u003eJ Clin Med\\u003c/em\\u003e (2022) 11:1583. doi: 10.3390/jcm11061583\\u003c/li\\u003e\\n\\u003cli\\u003eKulkarni C, Moorthy S, Sreekumar K, Rajeshkannan R, Nazar P, Sandya C, Sivasubramanian S, Ramchandran P. In the workup of patients with obscure gastrointestinal bleed, does 64-slice MDCT have a role? \\u003cem\\u003eIndian J Radiol Imaging\\u003c/em\\u003e (2012) 22:47\\u0026ndash;53. doi: 10.4103/0971-3026.95404\\u003c/li\\u003e\\n\\u003cli\\u003eGhoshal UC, Roy A, Goenka MK. Capsule endoscopy for small bowel bleed: Current update. \\u003cem\\u003eIndian J Gastroenterol\\u003c/em\\u003e (2024) 43:896\\u0026ndash;904. doi: 10.1007/s12664-024-01637-8\\u003c/li\\u003e\\n\\u003cli\\u003eYeh P-J, Wu R-C, Tsou Y-K, Chen C-M, Chiu C-T, Chen C-C, Lai M-W, Pan Y-B, Le P-H. Comparative Analysis of Cytomegalovirus Gastrointestinal Disease in Immunocompetent and Immunocompromised Patients. \\u003cem\\u003eViruses\\u003c/em\\u003e (2024) 16:452. doi: 10.3390/v16030452\\u003c/li\\u003e\\n\\u003cli\\u003eHsieh C-R, Wu R-C, Kuo C-J, Yeh P-J, Yeh Y-M, Chen C-L, Chiu C-T, Chiu C-H, Pan Y-B, Tsou Y-K, et al. Adequate antiviral treatment lowers overall complications of cytomegalovirus colitis among inpatients with inflammatory bowel diseases. \\u003cem\\u003eBMC Infect Dis\\u003c/em\\u003e (2024) 24:443. doi: 10.1186/s12879-024-09317-w\\u003c/li\\u003e\\n\\u003cli\\u003eWalti CS, Khanna N, Avery RK, Helanter\\u0026auml; I. New Treatment Options for Refractory/Resistant CMV Infection. \\u003cem\\u003eTranspl Int\\u003c/em\\u003e (2023) 36:11785. doi: 10.3389/ti.2023.11785\\u003c/li\\u003e\\n\\u003cli\\u003eYeh P-J, Wu R-C, Chiu C-T, Lai M-W, Chen C-M, Pan Y-B, Su M-Y, Kuo C-J, Lin W-R, Le P-H. Cytomegalovirus Diseases of the Gastrointestinal Tract. \\u003cem\\u003eViruses\\u003c/em\\u003e (2022) 14:352. doi: 10.3390/v14020352\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-infectious-diseases\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"infd\",\"sideBox\":\"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/infd\",\"title\":\"BMC Infectious Diseases\",\"twitterHandle\":\"#bmcinfectdis\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Cytomegalovirus enteritis, Obscure gastrointestinal bleed, Acute kidney injury, Type B aortic dissection\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8327970/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8327970/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eCytomegalovirus (CMV) enteritis is an uncommon clinical entity that frequently predisposes to severe complications, such as gastrointestinal (GI) hemorrhage and perforation, and is associated with substantial mortality.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCase Presentation\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe herein present the management of a case of CMV enteritis in an immunocompetent patient. The patient had a prior history of abdominal aortic replacement and bypass surgery for a type B aortic dissection, following which he developed acute kidney injury (AKI) stage 3 according to KDIGO guidelines. Approximately five weeks after the operation, he presented with massive gastrointestinal hemorrhage and was subsequently diagnosed with CMV enteritis. Treatment included exploratory laparotomy and antiviral therapy with ganciclovir, culminating in a successful recovery.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis case highlights the potential occurrence of CMV enteritis in individuals conventionally regarded as immunocompetent. Computed tomography (CT) plays a pivotal role in the early diagnosis of small bowel bleeding. Moreover, prompt surgical intervention constitutes an effective therapeutic strategy for hemorrhage control in this clinical scenario.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Cytomegalovirus enteritis in a patient with AKI after type B aortic dissection surgery: A case report\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-12-30 09:33:44\",\"doi\":\"10.21203/rs.3.rs-8327970/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-02-02T08:18:14+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-01-13T15:11:54+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-01-06T02:55:50+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"30149366766450151690639427396475913968\",\"date\":\"2026-01-06T01:50:55+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"254591624092862002816046193963163418661\",\"date\":\"2026-01-03T12:54:20+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-12-24T09:46:09+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-12-23T13:08:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-12-22T10:23:25+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-12-20T11:09:09+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Infectious Diseases\",\"date\":\"2025-12-20T11:03:22+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-infectious-diseases\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"infd\",\"sideBox\":\"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/infd\",\"title\":\"BMC Infectious Diseases\",\"twitterHandle\":\"#bmcinfectdis\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"351e6573-9c14-4fd9-a939-b8beadaa0a34\",\"owner\":[],\"postedDate\":\"December 30th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"in-revision\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-28T15:23:31+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-12-30 09:33:44\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8327970\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8327970\",\"identity\":\"rs-8327970\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}