Gastric cytomegalovirus infection in bone marrow transplant patients: an indication of generalized disease

Endoscopic diagnosis of cytomegalovirus gastritis after allogeneic hematopoietic stem cell transplantation

AIM: To clarify the endoscopic and clinical findings of cytomegalovirus (CMV) gastritis after allogeneic hematopoietic stem cell transplantation (allo-SCT).

METHODS: Between 1999 and 2005, 523 patients underwent allo-SCT at our hospital, and 115 of these patients with gastrointestinal symptoms underwent esophagogastroduodenoscopy.

RESULTS: CMV gastritis was diagnosed pathologically in seven patients (1.3%) with the other 108 patients serving as controls. Six of the seven patients developed positive CMV antigenemia, and five complained of abdominal pain. Development of abdominal pain preceded CMV antigenemia in four of the five patients. Endoscopic examination showed oozing (n = 2), erosion (n = 6), and redness (n = 5) in the seven patients with CMV gastritis, while the control patients showed oozing (n = 3), erosion (n = 24), and redness (n = 100). Erosion and oozing were more frequently documented in patients with CMV gastritis compared with the controls, and the differences were statistically significant (P = 0.0012 and 0.029, respectively). CMV inclusion bodies were documented in 12 of 14 biopsy specimens obtained from erosive lesions, while they were identified in 4 of 15 biopsy specimens obtained from lesions other than erosions (P = 0.0025).

CONCLUSION: This study suggests that erosion and oozing, as well as abdominal pain, are useful indicators in the diagnosis of CMV gastritis following allo-SCT.

Gastrointestinal cytomegalovirus disease in patients with cancer: a two decade experience in a tertiary care cancer center

Although gastrointestinal cytomegalovirus disease (GI-CMVd) is not common in cancer patients, it is associated with high morbidity and mortality. Herein, we review our 2-decade experience with GI-CMVd in such patient population at The University of Texas M.D. Anderson Cancer Center. Forty-seven patients were identified. Thirty-four patients (72%) had an underlying haematological malignancy, and 18 patients (38%) developed GI-CMVd following hematopoietic stem cell transplantation (HSCT). Nine (25%) of the 36 cancer patients with data available had AIDS. Upper-GI tract involvement was more common in patients with haematological malignancies than in those with solid tumours (P=0.02). Patients with AIDS were more likely to have colonic involvement than were those without AIDS (67% vs. 15%, P=0.006), and patients without AIDS were more likely to have gastric involvement (59% vs. 11%, P=0.01). The CMV-attributable mortality rate was 42%. Independent predictors of death by multivariate analysis included disseminated CMV and AIDS (P<0.01). The presentation of GI-CMVd varies according to the type of cancer, and AIDS. GI-CMVd is associated with a high mortality among cancer patients, particularly those with disseminated CMV disease or AIDS.

Gastrointestinal emergencies in patients with acute intestinal graft-versus-host disease

Acute intestinal graft-versus-host disease (GVHD) develops in about 30-50% of allogeneic bone-marrow transplant recipients: 10-20% have gastrointestinal emergencies (hemorrhage or perforation). Mortality reaches 30-60% in patients with acute, grade 2-4 GVHD. We studied 36 bone marrow recipients in whom acute intestinal GVHD developed. Seven had gastrointestinal emergencies: 4 severe gastrointestinal bleeding and 3 acute peritonitis. Three patients with gastrointestinal bleeding and one patient with peritonitis responded to medical therapy. Three needed surgery: one with bleeding and two with peritonitis, while 1 patient had embolization. Of the 7, two patients died, one after embolization and one after surgery. Two of the three surgically-treated cases are still alive several years after operation. From this experience we feel that surgery for gastrointestinal bleeding in acute GVHD is indicated only when medical treatment fails. Severe neutropenia, thrombocytopenia (<10.000 x mm3) and blood cultures positive for CMV have an unfavorable prognostic value.

Endoscopic appearance of the colon and small intestine of a patient with hemorrhagic enteric graft-vs.-host disease

Endoscopic appearance of the gastrointestinal tract of a patient with severe hemorrhagic enteric graft-vs.-host disease (GVHD) is presented. A 29-year-old man with chronic myelogenous leukemia suffered from severe enteric GVHD after allogeneic bone marrow transplantation. Endoscopy showed hemorrhagic ulceration of the upper jejunum, terminal ileum, and colon at the onset of melena. Sections of biopsies were compatible with acute GVHD. Repeat endoscopy showed gradual healing of the lesions after steroid pulse and antilymphocyte globulin therapy, but the patient died of cytomegalovirus pneumonitis 14 months later. Autopsy revealed submucosal fibrosis of the small intestine and colon.

Alimentary tract lesions in cytomegalovirus infection

Ten autopsy and 2 biopsy cases of cytomegalovirus (CMV) infection of the alimentary tract were studied. CMV infection was microscopically determined by the presence of cytomegalic inclusion as well as by the immunofluorescent method. Clinical manifestations such as abdominal pain, diarrhea, hematemesis, bloody stool, perforation, and/or abdominal distension with paralytic ileus were observed in 8 autopsy cases and 1 biopsy case. Disappearance of cytomegalic cells was confirmed by the follow-up study in the biopsy cases. Macroscopically, mucosal hemorrhage or ulceration was found in the gastrointestinal tract from the esophagus to the colon. Ulceration showed a characteristic well-defined punched-out appearance. The esophagus was the most frequently involved organ. However, no cytomegalic cells were found in the squamous epithelium. In the stomach, regenerated epithelial cells were frequently involved in the deeper part of glands. Numerous endothelial cells transformed into cytomegalic cells in the mucosa surrounding the ulcer in the esophagus, stomach, and intestine. Ischemia caused by cytomegalic changes of vascular endothelial cells is thought to play an important role in the pathogenesis of the ulcer of the gastrointestinal tract.

Computed tomography findings in gastrointestinal involvement by opportunistic organisms in acquired immune deficiency syndrome

The computed tomography findings in two cases of gastrointestinal superinfection by opportunistic organisms in acquired immune deficiency syndrome are presented. Findings included thickening of the mucosal folds and the bowel wall in the small intestine and colon associated with cytomegalovirus and cryptosporidiosis. These cases indicate that it is important to look carefully at the gastrointestinal tract when performing computed tomography in this group of patients. Unsuspected bowel pathology may be demonstrated, or disease may be confirmed in clinically suspected cases.

Esophageal infections in immunosuppressed patients after marrow transplantation

We reviewed all cases of infectious esophagitis diagnosed after marrow transplantation during a 2-yr period. Twenty-one infections were found during 46 fiberoptic endoscopic examinations; most infections were viral, with equal numbers due to cytomegalovirus and herpes simplex virus. These infections presented with nonspecific esophageal symptoms weeks to months after transplantation. Diagnoses depended on histology and viral cultures. During the same time span, autopsies revealed 25 cases of infective esophagitis among 59 patients; most were again viral, with equal numbers of herpes simplex virus and cytomegalovirus infections. Mixed infections due to viral, fungal, and bacterial pathogens were found in both endoscopy and autopsy series. The prevalence of esophageal infection in marrow transplant patients with esophageal symptoms is high, but the organisms could not be predicted on the basis of symptoms, oropharyngeal surveillance cultures, or esophageal x-ray. Accurate diagnosis requires that endoscopic biopsy specimens and brushings be examined by both histologic and virologic methods.

Disseminated intravascular coagulation induced by generalized cytomegalic inclusion disease during steroid therapy for polymyositis

A 56-year-old woman came to the hospital with fever and skin eruptions. A rise in myogenic enzyme and the presence of antileucocyte antibody were noticed, along with the gradual appearance of myalgia in both lower extremities, and muscle weakness. Steroid therapy was started under the diagnosis of polymyositis. The steroid was reduced because of mental disturbance but immediately the patient developed high fever. Various forms of treatment were carried out but there was no improvement, and the patient died. At autopsy there were scattered purpura on the skin, and the muscles were atrophic and yellowish-grey in color. Histopathologically, there was inflammatory cell infiltration and muscle fiber degeneration visible in many of the muscles, and the findings showed evidence of polymyositis. There were intranuclear inclusions in the lungs, ovaries, and adrenal glands, and this was diagnosed as generalized cytomegalic inclusion disease. Fibrin thrombi were found in the kidneys, lungs, and adrenal glands and this was pathologically diagnosed as disseminated intravascular coagulation. Endothelial cell damage caused by cytomegalovirus was assumed to be involved to a large extent in triggering the disseminated intravascular coagulation.