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Contreras-Valero JF, Ruíz-Ordóñez I, Pinilla-Monsalve GD, Bautista-Vargas M, Ocampo-Piraquive V, Aguirre-Valencia D. Cytomegalovirus infection and disease in systemic lupus erythematosus patients at a high-complexity hospital in southwestern Colombia. Lupus 2024; 33:797-803. [PMID: 38709545 DOI: 10.1177/09612033241247103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Cytomegalovirus (CMV) infection and disease is a condition usually described in immunocompromised patients, but among them, those with connective tissue diseases are poorly represented. Here we present the clinical, laboratory characteristics, management and outcomes of systemic lupus erythematosus (SLE) patients who presented with a CMV infection/disease to a high complexity hospital in southwestern Colombia between 2011 and 2020. 16 SLE patients were found to have a CMV infection. SLE was predominantly characterized by renal involvement (10 patients; 62.50%), and 14 patients (87.5%) were receiving steroids previous to the CMV infection. The entire sample required hospital admission, mainly related to acute kidney injury, and nine patients were admitted to the intensive care unit (ICU). Gastrointestinal organ damage was the most common CMV disease manifestation. All patients received ganciclovir, five of them (31.25%) suffered from septic shock, and seven (43.75%) died. Age ≥38 years and the presence of septic shock at admission were correlated to the mortality outcome. To our knowledge, this is the first publication evaluating SLE patients with CMV infection/disease in a Colombian population.
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Affiliation(s)
- Juan Fernando Contreras-Valero
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Ingrid Ruíz-Ordóñez
- GIRAT: Grupo de Investigación en Reumatología, Inmunología y Medicina Traslacional, School of Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad de Caldas, Manizales, Colombia
| | | | - Mario Bautista-Vargas
- Unidad de Reumatología, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Vanessa Ocampo-Piraquive
- GIRAT: Grupo de Investigación en Reumatología, Inmunología y Medicina Traslacional, School of Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
- Unidad de Reumatología, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - David Aguirre-Valencia
- GIRAT: Grupo de Investigación en Reumatología, Inmunología y Medicina Traslacional, School of Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
- Unidad de Reumatología, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
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Kim S, Yoon KW, Gil E, Yoo K, Choi KJ, Park CM. Emergency gastrointestinal tract operation associated with cytomegalovirus infection. Ann Surg Treat Res 2023; 104:119-125. [PMID: 36816733 PMCID: PMC9929438 DOI: 10.4174/astr.2023.104.2.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/25/2022] [Accepted: 12/05/2022] [Indexed: 02/10/2023] Open
Abstract
Purpose Cytomegalovirus (CMV) infection is common in immunocompromised patients. Enterocolitis caused by CMV infection can lead to perforation and bleeding of the gastrointestinal (GI) tract, which requires emergency operation. We investigated the demographics and outcomes of patients who underwent emergency operation for CMV infection of the GI tract. Methods This retrospective study was conducted between January 2010 and December 2020. Patients who underwent emergency GI operation and were diagnosed with CMV infection through a pathologic examination of the surgical specimen were included. The diagnosis was confirmed using immunohistochemical staining and evaluated by experienced pathologists. Results A total of 27 patients who underwent operation for CMV infection were included, 18 of whom were male with a median age of 63 years. Twenty-two patients were in an immunocompromised state. Colon (37.0%) and small bowel (37.0%) were the most infected organs. CMV antigenemia testing was performed in 19 patients; 13 of whom showed positive results. The time to diagnose CMV infection from operation and time to start ganciclovir treatment were median of 9 days. The reoperation rate was 22.2% and perforation was the most common cause of reoperation. In-hospital mortality rate was 25.9%. Conclusion CMV infection in the GI tract causes severe effects, such as hemorrhage or perforation, in immunocompromised patients. When these outcomes are observed in immunocompromised patients, suspicion of CMV infection and further evaluation for CMV detection in tissue specimens is required for proper treatment.
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Affiliation(s)
- Seijong Kim
- Division of Colorectal Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung Won Yoon
- Division of Critical Care, Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Eunmi Gil
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keesang Yoo
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Jin Choi
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi-Min Park
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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3
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Suga K, Nishiwaki A, Nakamura T, Kagami SI. Clinical significance of cytomegalovirus (CMV) pp65 antigenemia in the prediction of CMV infection during immunosuppressive therapy for rheumatic disease. Rheumatol Int 2022; 43:1093-1099. [PMID: 36042051 DOI: 10.1007/s00296-022-05196-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/22/2022] [Indexed: 10/14/2022]
Abstract
To investigate the risk factors for CMV infection and to clarify the cut-off count of CMV pp65 antigenemia predicting clinical symptoms related to CMV infection in patients with rheumatic disease. We retrospectively analyzed 261 patients with rheumatic disease who were treated with immunosuppressive therapy. CMV infection was defined as positive > 1 CMV-positive cell per two slides (CMV pp65 antigenemia C10/C11). Patients with CMV infection were divided into two groups based on the presence of antiviral treatment for CMV disease. We determined a cut-off value of CMV-positive cells for the diagnosis of CMV disease. CMV infection was observed in 141 cases (54%). In a multivariate analysis, CMV infection was associated with three following factors: Age > 60 years (OR 1.87 [95% CI 1.04-3.36]); lymphocyte counts < 1000/μL (OR 3.34 [95% CI 1.88-6.05]); steroid pulse therapy (OR 2.60 [95% CI 1.27-5.55]). The cut-off level of CMV pp65 antigenemia indicating CMV disease was five positive cells average two slides by using receiver operating characteristic curve analysis (AUC 0.95, sensitivity 0.94, specificity 0.80). Age > 60 years, lymphocytopenia (< 1000/μL) and steroid pulse therapy are risk factors of CMV infection. We recommend that CMV pp65 antigenemia of > 5 cells average two slides (C10/C11) in patients with rheumatic disease should be the treated with antiviral drugs.
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Affiliation(s)
- Kensuke Suga
- Research Center for Allergy and Clinical Immunology, Asahi General Hospital, 1326 Asahi, Chiba, 289-2511, Japan.
| | - Aya Nishiwaki
- Research Center for Allergy and Clinical Immunology, Asahi General Hospital, 1326 Asahi, Chiba, 289-2511, Japan
| | - Takayuki Nakamura
- Research Center for Allergy and Clinical Immunology, Asahi General Hospital, 1326 Asahi, Chiba, 289-2511, Japan
| | - Shin-Ichiro Kagami
- Research Center for Allergy and Clinical Immunology, Asahi General Hospital, 1326 Asahi, Chiba, 289-2511, Japan
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4
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Xu Y, Chen M, Xie L, Zhang X, Wang Y, Gu X. Cytomegalovirus-Associated Nephrotic Syndrome in a Patient with Myasthenia Gravis Treated with Azathioprine: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933380. [PMID: 34582431 PMCID: PMC8488190 DOI: 10.12659/ajcr.933380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients taking azathioprine (AZA) are very susceptible to development of cytomegalovirus (CMV) infection. The symptoms of CMV infection are varied. In some rare cases, CMV infection can even result in nephrotic syndrome. CASE REPORT Here, we present a rare case of nephrotic syndrome associated with CMV infection, induced by azathioprine intake. The patient, diagnosed with myasthenia gravis, was initially treated with azathioprine for 2 years. Then, the patient was admitted to the hospital due to nephrotic syndrome and acute kidney injury. Minimal change disease with acute tubular necrosis were diagnosed through biopsy. After an initial good response to hemodialysis and steroids, the patient developed severe pneumonia and oral ulcers. Further anti-CMV IHC staining of kidney tissues showed positive cells in tubules, indicating nephrotic syndrome secondary to CMV infection. CONCLUSIONS This case reminded us that CMV may be an under-recognized cause of nephrotic syndrome. Patients treated with azathioprine are very susceptible to developing CMV infection. During the diagnosis of nephrotic syndrome, we should always take CMV infection into consideration, especially in patients with on azathioprine.
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Affiliation(s)
- Yanqiu Xu
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
| | - Min Chen
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
| | - Lin Xie
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
| | - Xi Zhang
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
| | - Yi Wang
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
| | - Xiangchen Gu
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China (mainland)
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Yeh PJ, Chiu CT, Lai MW, Wu RC, Chen CM, Kuo CJ, Hsu JT, Su MY, Lin WP, Chen TH, Le PH. Clinical manifestations, risk factors, and prognostic factors of cytomegalovirus enteritis. Gut Pathog 2021; 13:53. [PMID: 34407879 PMCID: PMC8371416 DOI: 10.1186/s13099-021-00450-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 08/12/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND To comprehensively analyze the risk factors, clinical characteristics, outcomes, and prognostic factors of Cytomegalovirus (CMV) enteritis. METHODS This retrospective cohort study enrolled patients who had undergone pathological examinations for CMV enteritis. They were divided into CMV and non-CMV groups according to immunohistochemistry staining results. The risk factors, clinical presentations, endoscopic features, treatments, outcomes, and prognostic factors of CMV enteritis were then analyzed. RESULTS Forty-two patients (18 CMV, 24 non-CMV group) were included in the study. Major clinical presentations in the CMV group included gastrointestinal bleeding (72.2%), abdominal pain (55.6%), and fever (33.3%); ulcers (72.2%) were the most common endoscopic findings. In-hospital and overall mortality rates were 27.8% and 38.9%, respectively; and longer hospital stays and higher overall mortality rates were observed. Radiotherapy and C-reactive protein levels were prognostic factors for in-hospital mortality. The risk factors for CMV enteritis included immunocompromised status (p = 0.013), steroid use (p = 0.014), shock (p = 0.031), concurrent pneumonia (p = 0.01), antibiotic exposure (p < 0.001), radiotherapy (p = 0.027), chronic kidney disease (p = 0.041), and CMV colitis (p = 0.031). CONCLUSIONS Physicians should pay attention to the characteristics of CMV enteritis in high-risk patients to make an early diagnosis and potentially improve the clinical outcome.
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Affiliation(s)
- Pai-Jui Yeh
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.,Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan
| | - Ming-Wei Lai
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.,Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan.,Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Ren-Chin Wu
- Department of Pathology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chien-Ming Chen
- Department of Medical Imaging and Interventions, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chia-Jung Kuo
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.,Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Department of General Surgery, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Ming-Yao Su
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan.,Department of Gastroenterology and Hepatology, New Taipei City Municipal Tucheng Hospital (Chang Gung Memorial Hospital, Tucheng Branch), New Taipei City, Taiwan
| | - Wei-Pin Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.,Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan
| | - Tsung-Hsing Chen
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.,Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan. .,Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan. .,Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.
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6
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Sugawara E, Matsui K, Amasaki Y. Cytomegalovirus Enteritis in a Patient with Rheumatoid Arthritis Receiving Baricitinib. J Rheumatol 2020; 47:1835-1836. [PMID: 33262287 DOI: 10.3899/jrheum.191395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Eri Sugawara
- Department of Rheumatology, Tonan Hospital, Sapporo, Japan.
| | - Kazuo Matsui
- Department of Rheumatology, Tonan Hospital, Sapporo, Japan
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7
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Onpoaree N, Veeravigrom M, Sanpavat A, Suratannon N, Sintusek P. Unremitting diarrhoea in a girl diagnosed anti-N-methyl-D-aspartate-receptor encephalitis: A case report. World J Clin Cases 2020; 8:4866-4875. [PMID: 33195655 PMCID: PMC7642535 DOI: 10.12998/wjcc.v8.i20.4866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/27/2020] [Accepted: 09/25/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Asymptomatic cytomegalovirus (CMV) infection is common in children; in contrast, in children with a weakened immune system, invasive CMV can occur. This is the first case report of a severe manifestation of CMV esophago-enterocolitis in a girl diagnosed with anti-N-methyl-D-aspartate-receptor (anti-NMDAR) encephalitis who received only a moderate dose of corticosteroid therapy.
CASE SUMMARY A 12-year-old-Thai girl presented with acute behavioural change and headache for 6 d. Electroencephalogram and positivity for NMDAR autoantibodies were compatible with anti-NMDAR encephalitis. Hence, she received pulse methylprednisolone 10 mg/kg per day for 4 d and continued with prednisolone 1.2 mg/kg per day. On day 42 of corticosteroid therapy, she developed unremitting vomiting and diarrhoea. Endoscopy showed multiple ulcers and erythaematous mucosa along the gastrointestinal tract. Tissue CMV viral load and viral-infected cells confirmed CMV esophago-enterocolitis. Therefore, the patient received ganciclovir 5 mg/kg per dose every 12 h for 3 wk and then 5 mg/kg per dose once daily for 3 wk. Unremitting diarrhoea slowly improved from stool output 1-4 L per day to 1-2 L per day after 3 wk of treatment. Pulse methylprednisolone 20 mg/kg for 5 d was initiated and continued with prednisolone 1 mg/kg per day. After this repeated pulse methylprednisolone treatment, surprisingly, diarrhoea subsided. Immunologic work-up was performed to rule out underlying immune deficiency with unremarkable results.
CONCLUSION Unremitting diarrhoea from CMV esophago-enterocolitis subsided with antiviral and methylprednisolone therapy, implying the immune and NMDAR dysregulation in anti-NMDAR encephalitis.
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Affiliation(s)
- Norrapat Onpoaree
- Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Montida Veeravigrom
- Division of Neurology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Anapat Sanpavat
- Division of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Narissara Suratannon
- Division of Allergy, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Palittiya Sintusek
- Division of Gastroenterology and Pediatric Gastroenterology and Hepatology Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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8
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Chen D, Zhao R, Cao W, Zhou W, Jiang Y, Zhang S, Chen Y, Fei G, Li J, Qian J. Clinical characteristics of cytomegalovirus gastritis: A retrospective study from a tertiary medical center. Medicine (Baltimore) 2020; 99:e18927. [PMID: 32000406 PMCID: PMC7004595 DOI: 10.1097/md.0000000000018927] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Cytomegalovirus (CMV) gastritis is a rare opportunistic infection with diverse clinical manifestations. Our study aimed to investigate the clinical features of Chinese patients with CMV gastritis.Six inpatients diagnosed with CMV gastritis were retrospectively enrolled, based on the finding of inclusion bodies in routine hematoxylin and eosin staining or positive anti-CMV monoclonal antibodies under immunohistochemistry in the gastric biopsy. Data, including demographics, diagnostic measurements, and medications, were collected.Abdominal pain was the most frequently reported symptom, occurring in 4 patients. Five patients were immunocompromised with associated underlying diseases, and 3 patients had decreased leukocyte differentiation antigen 4 positive (CD4) T lymphocyte counts. Only 3 patients had either positive cytomegalovirus (CMV)-immunoglobulin (Ig) M or increased copies of CMV-DNA peripherally. All patients had gastric lesions in the antrum of the stomach, including ulcers or erosions observed by gastroscopy. All patients received ganciclovir by intravenous injection (IV) as the first line anti-CMV therapy, and attained complete (4) or partial remission (2) during the follow-up.CMV gastritis should be taken into consideration in patients with immunocompromised status who have abdominal pain, nausea, or vomiting. Gastroscopy and necessary biopsy are the major diagnostic methods for CMV gastritis. Early diagnosis leads to a better prognosis for these patients.
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Affiliation(s)
| | | | - Wei Cao
- Department of Infectious Diseases
| | | | | | - Shangzhu Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | | | - Ji Li
- Department of Gastroenterology
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9
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Yamamoto S, Iwamuro M, Miyake M, Nishimura N, Mizuno M, Okada H. Severe Bleeding due to Cytomegalovirus Esophagitis in a Patient with Diabetes after Interbody Fusion Surgery. Intern Med 2019; 58:2949-2955. [PMID: 31292384 PMCID: PMC6859388 DOI: 10.2169/internalmedicine.2908-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A 49-year-old man with diabetes taking clopidogrel and celecoxib underwent interbody fusion surgery for spinal spondylolysis. Ten days after the surgery, he vomited a large amount of fresh blood. A blood examination revealed hemodynamic failure. Esophagogastroduodenoscopy showed an adherent blood clot and multiple superficial ulcers in the esophagus. Endoscopic hemostasis was successfully achieved. Biopsy specimens from the esophageal ulcer showed positive immunohistochemical staining results for anti-CMV antibodies. The esophageal ulcer improved after the oral administration of ganciclovir. This case emphasizes that CMV esophagitis with bleeding can occur in a diabetic patient with a poor nutritional status due to relative immune dysfunction.
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Affiliation(s)
- Shumpei Yamamoto
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Japan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Muneaki Miyake
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Japan
| | - Naoyuki Nishimura
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Japan
| | - Motowo Mizuno
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
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10
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Campos Costa F, Freitas J, Oliveira M, Malcata A. Lupus nephritis complicated by cytomegalovirus colitis, aspergillosis and brain abscess. Lupus 2019; 28:1495-1497. [PMID: 31474190 DOI: 10.1177/0961203319872549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- F Campos Costa
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - J Freitas
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - M Oliveira
- Rheumatology Department, Centro Hospitalar Cova da Beira, Covilhã, Portugal.,Faculty of Health Sciences, University Beira Interior, Covilhã, Portugal
| | - A Malcata
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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11
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Reactivation of latent cytomegalovirus infection in patients with rheumatologic disease: a case-control study. Rheumatol Int 2019; 39:1229-1240. [PMID: 31076831 DOI: 10.1007/s00296-019-04324-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
Abstract
The disease burden, risk factors and clinical sequelae of CMV reactivation in patients with rheumatologic conditions is poorly understood. We have described a cohort with underlying rheumatic disease and CMV, and compared a subgroup with systemic lupus erythematosus (SLE) to controls to identify potential risk factors for CMV reactivation. Adults with rheumatic disease and CMV infection from 2000-2015 were identified. SLE cases were matched 3:1 with controls based on age, sex and year of admission, and compared. Fourteen patients were included (6 SLE, 4 rheumatoid arthritis, 2 sarcoidosis, 1 psoriatic arthritis, 1 microscopic polyangiitis). Seven had viremia alone, the remainder tissue-invasive disease. Thirteen received glucocorticoids prior to CMV reactivation. Fever was the most common symptom, and coinfections were seen in eight including four with bacteremia. Thirteen received antiviral therapy (median 33 days), four died during hospitalization. Six patients with underlying SLE and CMV reactivation were compared to 18 SLE controls. Cases received more glucocorticoids prior to admission (median 36.5 vs. 2.5 mg/day, p = 0.006), had longer hospitalizations (median 47 vs. 7 days, p = 0.006) and more coinfections (67% vs. 17%, p = 0.04). There were no significant differences in symptoms at presentation. CMV reactivation occurs in patients with rheumatologic disease, can result in severe clinical sequelae, and is difficult to distinguish from a flare of the underlying disease. Patients with CMV received higher doses of glucocorticoids and developed more co-infections. CMV should be considered during the evaluation of a febrile illness in this complex patient population.
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12
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Yokose T, Obara H, Shinoda M, Nakano Y, Kitago M, Yagi H, Abe Y, Yamada Y, Matsubara K, Oshima G, Hori S, Ibuki S, Higashi H, Masuda Y, Hayashi M, Mori T, Kawaida M, Fujimura T, Hoshino K, Kameyama K, Kuroda T, Kitagawa Y. Colon perforation due to antigenemia-negative cytomegalovirus gastroenteritis after liver transplantation: A case report and review of literature. World J Gastroenterol 2019; 25:1899-1906. [PMID: 31057303 PMCID: PMC6478612 DOI: 10.3748/wjg.v25.i15.1899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/03/2019] [Accepted: 03/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) remains a critical complication after solid-organ transplantation. The CMV antigenemia (AG) test is useful for monitoring CMV infection. Although the AG-positivity rate in CMV gastroenteritis is known to be low at onset, almost all cases become positive during the disease course. We treated a patient with transverse colon perforation due to AG-negative CMV gastroenteritis, following a living donor liver transplantation (LDLT).
CASE SUMMARY The patient was a 52-year-old woman with decompensated liver cirrhosis as a result of autoimmune hepatitis who underwent a blood-type compatible LDLT with her second son as the donor. On day 20 after surgery, upper and lower gastrointestinal endoscopy (GE) revealed multiple gastric ulcers and transverse colon ulcers. The biopsy tissue immunostaining confirmed a diagnosis of CMV gastroenteritis. On day 28 after surgery, an abdominal computed tomography revealed transverse colon perforation, and simple lavage and drainage were performed along with an urgent ileostomy. Although the repeated remission and aggravation of CMV gastroenteritis and acute cellular rejection made the control of immunosuppression difficult, the upper GE eventually revealed an improvement in the gastric ulcers, and the biopsy samples were negative for CMV. The CMV-AG test remained negative, therefore, we had to evaluate the status of the CMV infection on the basis of the clinical symptoms and GE.
CONCLUSION This case report suggests a monitoring method that could be useful for AG-negative CMV gastroenteritis after a solid-organ transplantation.
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Affiliation(s)
- Takahiro Yokose
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Yutaka Nakano
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Yohei Yamada
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Go Oshima
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Sho Ibuki
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Hisanobu Higashi
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Yuki Masuda
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Masanori Hayashi
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Miho Kawaida
- Department of Pathology, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Takumi Fujimura
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Ken Hoshino
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Kaori Kameyama
- Department of Pathology, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Tatsuo Kuroda
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan
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13
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Martínez Huguet C, Arguedas Lázaro Y, Del Valle Sánchez E, Omiste Sanvicente T, Bernal Monterde V, Montoro Huguet M. Cytomegalovirus associated with gastric ulcer: case report and literature review. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:256-258. [PMID: 30007786 DOI: 10.1016/j.gastrohep.2018.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 05/10/2018] [Accepted: 05/24/2018] [Indexed: 06/08/2023]
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14
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Hoversten P, Kamboj AK, Katzka DA. Infections of the esophagus: an update on risk factors, diagnosis, and management. Dis Esophagus 2018; 31:5123414. [PMID: 30295751 DOI: 10.1093/dote/doy094] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/28/2018] [Indexed: 12/11/2022]
Abstract
Infectious esophagitis is a leading cause of esophagitis worldwide. While esophageal infections have traditionally been associated with immunocompromised patients, these disorders are becoming increasingly recognized in immunocompetent individuals. The three most common etiologies of infectious esophagitis are Candida, herpes simplex virus, and cytomegalovirus. Human papilloma virus infection can also involve the esophagus in the form of ulcerative lesions and papillomas. Less common etiologies include various other fungal, bacterial, and viral organisms. This review provides a comprehensive update on risk factors, diagnosis, and management of both common and less common infections of the esophagus.
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Affiliation(s)
- P Hoversten
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - A K Kamboj
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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15
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Real-time quantitative PCR analysis of endoscopic biopsies for diagnosing CMV gastrointestinal disease in non-HIV immunocompromised patients: a diagnostic accuracy study. Eur J Clin Microbiol Infect Dis 2018; 37:2389-2396. [PMID: 30255430 DOI: 10.1007/s10096-018-3387-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/19/2018] [Indexed: 12/27/2022]
Abstract
Cytomegalovirus gastrointestinal diseases (CMV-GIDs) are end-organ diseases of the gastrointestinal (GI) tract caused by CMV in immunocompromised patients. We aimed to evaluate the performance of quantitative polymerase chain reaction (qPCR) on endoscopic biopsies. We retrospectively reviewed the qPCR data on endoscopic biopsies in nonhuman immunodeficiency virus (HIV) immunocompromised patients between January 2009 and May 2015. The performance of the qPCR for CMV-GID was evaluated with the sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). A total of 195 patients were included, and 28 patients with confirmed CMV-GID were identified. The AUROC of the qPCR was 0.935 (95% confidence interval [CI], 0.885 to 0.985), the sensitivity was 89.3% (95% CI, 71.8 to 97.7%), and the specificity was 85.6% (95% CI, 79.4 to 97.6%) with a cutoff value of 180 copies/μg DNA. The proportion of patients with inflammatory bowel disease in the histopathology-negative, PCR-positive group was smaller than that in the histopathology-positive group (10.7 vs 35.0%, p = 0.026), but other characteristics were not significantly different. The use of qPCR on endoscopic biopsies demonstrated good diagnostic performance for detecting CMV in non-HIV immunocompromised patients. It may increase the diagnostic yield when combined with a conventional histopathology.
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16
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Abstract
This manuscript presents a review of infectious causes of gastritis aimed at the practicing anatomic pathologist. We shall highlight unique histologic findings and clinical attributes that will assist those analyzing endoscopically obtained mucosal biopsies of the stomach or resection specimens.
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17
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Matsuda K, Ono S, Ishikawa M, Miyamoto S, Abiko S, Tsuda M, Yamamoto K, Kudo T, Shimizu Y, Hayase E, Hashimoto D, Teshima T, Matsuno Y, Sakamoto N. Cecum ulcer is a reliable endoscopic finding in cytomegalovirus colitis concomitant with graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Ann Hematol 2018; 97:877-883. [PMID: 29340759 DOI: 10.1007/s00277-018-3241-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/05/2018] [Indexed: 12/13/2022]
Abstract
Although graft-versus-host disease (GVHD) is the major complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT), cytomegalovirus (CMV) reactivation also occurs in patients after allo-HSCT and these conditions often clinically overlap. The aim of this study was to determine reliable endoscopic findings of CMV colitis in patients with gastrointestinal graft-versus-host-disease (GI-GVHD). Patients after allo-HSCT who were histologically confirmed to have GI-GVHD with or without CMV colitis and patients with an immunosuppressive condition were retrospectively analyzed. We divided the patients into three groups: GI-GVHD with CMV colitis (group A), GI-GVHD without CMV colitis (group B), and CMV colitis without undergoing allo-HSCT (group C). From medical records, the involved colorectal areas and endoscopic findings according to the groups were compared. A total of 70 patients were divided into three groups (group A: n = 19, group B: n = 28, group C: n = 23). Mucosal injuries in groups A and C frequently occurred in the cecum including ileocecal valves. On the other hand, there were no abnormal lesions on ileocecal valves in group B. Furthermore, ulcer lesions were more frequently observed in groups A and C than in group B (p < 0.001). The sensitivity and specificity of mucosal injuries in the cecum for prediction of CMV colitis were 89.5 and 76.5%, respectively, and mucosal injuries in the cecum were more reliable findings than CMV antigenemia. Ulcer lesions in the cecum are reliable endoscopic findings for CMV colitis in patients with GI-GVHD after allo-HSCT.
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Affiliation(s)
- Kana Matsuda
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Shoko Ono
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan.
| | - Marin Ishikawa
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Shuichi Miyamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Satoshi Abiko
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Momoko Tsuda
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Keiko Yamamoto
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Takahiko Kudo
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuichi Shimizu
- Division of Endoscopy, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Eiko Hayase
- Department of Hematology, Hokkaido University Faculty of Medicine, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Daigo Hashimoto
- Department of Hematology, Hokkaido University Faculty of Medicine, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Yoshihiro Matsuno
- Department of Pathology, Hokkaido University Hospital, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine, Nishi-7, Kita-15, Kita-ku, Sapporo, 060-8638, Japan
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18
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Soriano A, Smerieri N, Bonilauri S, De Marco L, Cavazza A, Salvarani C. Colonic perforation due to severe cytomegalovirus disease in granulomatosis with polyangiitis after immunosuppression. Clin Rheumatol 2018; 37:1427-1432. [PMID: 29302827 DOI: 10.1007/s10067-017-3945-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/26/2017] [Accepted: 12/04/2017] [Indexed: 12/19/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a small-vessel necrotizing granulomatous vasculitis typically involving upper airways, lungs, and kidneys, which may lead to end-organ damage and life-threatening complications. Major infections during GPA course represent a considerable concern in the management of the disease. Cytomegalovirus (CMV) infection and disease are rare but significant complications in the course of GPA being associated with high morbidity and mortality rates. Colonic perforation due to CMV colitis is exceedingly rare and has so far almost exclusively been documented in HIV, renal transplant, and systemic lupus erythematosus patients. We reported the case of a patient affected with upper airways-limited GPA who developed acute renal failure from rapidly progressive glomerulonephritis and then experienced colonic perforation due to CMV colitis a few weeks after immunosuppressive treatment with high-dose steroids and cyclophosphamide (CYC) for remission induction of the disease. We also reviewed the literature on CMV-related gastro-intestinal complications in the course of GPA and discussed contributing factors to severe manifestations of CMV infection and its reactivation.
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Affiliation(s)
- Alessandra Soriano
- Rheumatology Unit, Department of Internal Medicine, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy. .,Campus Bio-Medico University, Rome, Italy.
| | - Nazareno Smerieri
- General and Emergency Surgery, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy.
| | - Stefano Bonilauri
- General and Emergency Surgery, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy
| | - Loredana De Marco
- Pathology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy
| | - Alberto Cavazza
- Pathology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Department of Internal Medicine, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy
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19
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Marques S, Carmo J, Pinto D, Bispo M, Ramos S, Chagas C. Cytomegalovirus Disease of the Upper Gastrointestinal Tract: A 10-Year Retrospective Study. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2017; 24:262-268. [PMID: 29255766 DOI: 10.1159/000479232] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/23/2017] [Indexed: 12/28/2022]
Abstract
Background and Aims Cytomegalovirus (CMV) disease of the gastrointestinal (GI) tract is a major cause of morbidity and mortality in immunocompromised patients. The colon is the most commonly affected site, and the literature is scarce regarding CMV disease of the upper GI tract. Therefore, our study aimed to evaluate the clinical and endoscopic features of upper GI CMV disease. Methods This 10-year retrospective study included all patients with a histopathological diagnosis of upper GI CMV infection. Patients' clinical, endoscopic, therapy, and follow-up data were collected from medical records. Results Twelve patients with histopathologically proven upper GI CMV disease were identified (age 61 ± 18 years, 50% men). Most of the patients were immunocompromised (75%) due to acquired immunodeficiency syndrome (AIDS), malignancy, and/or immunosuppressive therapy. In the remainder (25%), the disease occurred in the absence of immunodeficiency and immunosuppression. Three patients (all with AIDS) presented with disseminated CMV infection. In the majority of the cases (83%), upper GI CMV disease was symptomatic, and the most common clinical presentations were odynophagia/dysphagia (25%) and nausea/vomiting (25%). Endoscopically, there were 5 cases of esophagitis (42%) and 7 cases of gastritis (58%). The lower esophagus (33%) and the gastric antrum (42%) were the most frequently affected GI sites. Regardless of the location, mucosal ulceration was the most common endoscopic finding (75%) and was associated with very deep ulceration resembling cavitation in 2 cases. Other endoscopic features were mucosal edema, hyperemia, and nodularity (25%). Eleven patients (92%) received antiviral treatment (duration 26 ± 12 days). The 1-month and 1-year mortality rates were 16.7 and 25%, respectively. Conclusions Upper GI CMV disease can occur in the absence of immunodeficiency and immunosuppression. It is usually symptomatic, and mucosal ulceration is often evident at endoscopy. It is associated with significant mortality; therefore, early diagnosis and adequate antiviral treatment are essential.
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Affiliation(s)
| | - Joana Carmo
- Department of Gastroenterology, Lisbon, Portugal
| | - Daniel Pinto
- Department of Pathology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Bispo
- Department of Gastroenterology, Lisbon, Portugal
| | - Sância Ramos
- Department of Pathology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
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20
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Bayer AL, Fraker CA. The Folate Cycle As a Cause of Natural Killer Cell Dysfunction and Viral Etiology in Type 1 Diabetes. Front Endocrinol (Lausanne) 2017; 8:315. [PMID: 29218028 PMCID: PMC5703744 DOI: 10.3389/fendo.2017.00315] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/30/2017] [Indexed: 12/15/2022] Open
Abstract
The folate pathway is critical to proper cellular function and metabolism. It is responsible for multiple functions, including energy (ATP) production, methylation reactions for DNA and protein synthesis and the production of immunomodulatory molecules, inosine and adenosine. These play an important role in immune signaling and cytotoxicity. Herein, we hypothesize that defects in the folate pathway in genetically susceptible individuals could lead to immune dysfunction, permissive environments for chronic cyclical latent/lytic viral infection, and, ultimately, the development of unchecked autoimmune responses to infected tissue, in this case islet beta cells. In the context of type 1 diabetes (T1D), there has been a recent increase in newly diagnosed cases of T1D in the past 20 years that has exceeded previous epidemiological predictions with yet unidentified factor(s). This speaks to a potential environmental trigger that adversely affects immune responses. Most research into the immune dysfunction of T1D has focused on downstream adaptive responses of T and B cells neglecting the role of the upstream innate players such as natural killer (NK) cells. Constantly, surveilling the blood and tissues for pathogens, NK cells remove threats through direct cytotoxic responses and recruitment of adaptive responses using cytokines, such as IL-1β and IFN-γ. One long-standing hypothesis suggests viral infection as a potential trigger for the autoimmune response in T1D. Recent data suggest multiple viruses as potential causal agents. Intertwined with this is an observed reduced NK cell enumeration, cytotoxicity, and cytokine signaling in T1D patients. Many of the viruses implicated in T1D are chronic latent/lysogenic infections with demonstrated capacity to reduce NK cell response and number through mechanisms that resemble those of pregnancy tolerance. Defects in the folate pathway in T1D patients could result in decreased immune response to viral infection or viral reactivation. Dampened NK responses to infections result in improper signaling, improper antigen presentation, and amplified CD8+ lymphocyte proliferation and cytotoxicity, a hallmark of beta cell infiltrates in patients with T1D onset. This would suggest a critical role for NK cells in T1D development linked to viral infection and the importance of the folate pathway in maintaining proper NK response.
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Affiliation(s)
- Allison L. Bayer
- Immunobiology Laboratory, Leonard M. Miller School of Medicine, Diabetes Research Institute, University of Miami, Miami, FL, United States
| | - Christopher A. Fraker
- Tissue and Biomedical Engineering Laboratory, Leonard M. Miller School of Medicine, Diabetes Research Institute, University of Miami, Miami, FL, United States
- *Correspondence: Christopher A. Fraker,
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21
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Wang HW, Kuo CJ, Lin WR, Hsu CM, Ho YP, Lin CJ, Su MY, Chiu CT, Wang CL, Chen KH. The clinical characteristics and manifestations of cytomegalovirus esophagitis. Dis Esophagus 2016; 29:392-9. [PMID: 25715747 DOI: 10.1111/dote.12340] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophagitis is the second most common gastrointestinal manifestation of cytomegalovirus (CMV) infection after colitis. CMV esophagitis has been reported in patients who have undergone transplantation, are on long-term renal dialysis, or who have the human immunodeficiency virus infection. This study aimed to investigate the clinical characteristics and manifestations of CMV esophagitis in patients who underwent diagnostic endoscopy. A total of 16 patients with histologically proven CMV infection were identified from 1539 patients with esophageal ulcers and analyzed retrospectively (January 2006 to December 2013). Patients' personal data (age, smoking, and alcohol consumption), underlying systemic diseases (diabetes mellitus, end-stage renal disease, and chronic obstructive pulmonary disease), malignancy, indication for esophagogastroduodenoscopy, endoscopic characteristics, and diagnostic methods (pathological or serological findings) were collected for further analysis. Among the patients with CMV esophagitis, the mean age was 59.94 years (range, 23-84 years). The male : female ratio was 1.67:1. Odynophagia and epigastralgia were common symptoms. Of the 16 patients, 3 (18.75%) were infected with the human immunodeficiency virus and 9 (56.25%) had an underlying malignancy, including lung cancer (6 patients), esophageal cancer (2 patients), gastric cancer (1 patient), ampulla of Vater cancer (1 patient), and lymphoma (1 patient). Six of the 9 patients (66.7%) with malignancy had been administered concurrent chemoradiotherapy (CCRT). In this study, patients with malignancy who had been administered CCRT were at increased risk for CMV esophagitis, which had not been reported before in the literature. CMV esophagitis should be considered as a potential treatment-related complication of CCRT.
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Affiliation(s)
- H-W Wang
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - C-J Kuo
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - W-R Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-M Hsu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Y-P Ho
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - C-J Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - M-Y Su
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-T Chiu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-L Wang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - K-H Chen
- Department of Pathology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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22
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Abstract
Epigastric pain is an extremely common complaint in the emergency department and has an associated broad differential diagnosis. In the differential it is important to consider cardiac causes that may be mistaken for gastrointestinal disorders as well as various serious intra-abdominal causes. This article highlights the limitations in laboratory testing and guides providers through the appropriate considerations for advanced imaging. Special attention is focused on acute pancreatitis, esophageal emergencies, and peptic ulcer disease/gastritis and their associated complications.
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Affiliation(s)
- Patrick Robinson
- Virginia Tech Carilion Emergency Medicine Residency, Department of Emergency Medicine, 1 Riverside Circle, 4th Floor, Roanoke, VA 24016, USA.
| | - John C Perkins
- Virginia Tech Carilion Emergency Medicine Residency, Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, 4th Floor, Roanoke, VA 24016, USA
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23
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Almanzar G, Schmalzing M, Trippen R, Höfner K, Weißbrich B, Geissinger E, Meyer T, Liese J, Tony HP, Prelog M. Significant IFNγ responses of CD8+ T cells in CMV-seropositive individuals with autoimmune arthritis. J Clin Virol 2016; 77:77-84. [PMID: 26921739 DOI: 10.1016/j.jcv.2016.02.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/27/2016] [Accepted: 02/16/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Latent Cytomegalovirus (CMV) infection accelerates immunosenescence in elderly with reactivations reported in Rheumatoid Arthritis (RA) and abnormal responses towards CMV in Juvenile Idiopathic Arthritis (JIA). OBJECTIVES Considering the signs of premature T-cell immunosenescence in arthritis patients, the known effect of CMV latency on speeding up many of these signs in an age-dependent manner and the role of CMV on IFNγ-mediated inflammation in healthy elderly and RA, we hypothesized that latent CMV infection accelerates TCR repertoire restriction, loss of CD28, peripheral T-cell proliferation and aberrant IFNγ responses in arthritis patients. STUDY DESIGN Unspecific and CMVpp65-specific IFNγ responses were investigated in peripheral CD8+ T-cells in RA or JIA patients and healthy, age-matched controls. RESULTS Despite higher prevalence and concentrations of IgG-anti-CMV, arthritis patients showed lower unspecific IFNγ production, lower CD69-mediated activation and lower CD8+ T-cell proliferation. CMV-seropositive RA patients showed higher intracellular IFNγ production and increased proportions of CD28-CD8+ T-cells after specific CMVpp65 long-term stimulation which was not altered by in vitro blockade of TNFα or IL-6. A skewed TCR repertoire towards oligoclonality and less polyclonality was found in JIA. DISCUSSION CMVpp65-specific IFNγ production with expansion of CD28-CD8+ T-cells suggests an efficient control of latent CMV regardless of immunosuppressive therapy or in vitro blockade of TNFα or IL-6 in CMV-seropositive arthritis patients. Increased IgG-anti-CMV antibody concentrations and increased proportions of intracellular IFNγ-producing CMVpp65-specific CD8+ T-cells in long-term cultures propose a possibly role of endogenous CMV reactivations boosting antibody levels and a higher possibly CMV-driven IFNγ-mediated inflammatory potential of CD8+ T-cells in arthritis patients.
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Affiliation(s)
- Giovanni Almanzar
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany.
| | - Marc Schmalzing
- Department of Internal Medicine II, Rheumatology and Immunology, University Hospital Würzburg, Würzburg, Germany
| | - Raimund Trippen
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Kerstin Höfner
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Benedikt Weißbrich
- Institute of Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | - Eva Geissinger
- Institute of Pathology, University of Würzburg, Würzburg, Germany
| | - Thomas Meyer
- Pediatric Surgery Unit, Department of Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Johannes Liese
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Hans-Peter Tony
- Department of Internal Medicine II, Rheumatology and Immunology, University Hospital Würzburg, Würzburg, Germany
| | - Martina Prelog
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
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24
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Abstract
PURPOSE OF REVIEW Infectious esophagitis generally occurs in patients with impaired immunity. Although methods to suppress the immune system evolve, the potential infectious consequences are poorly understood. The purpose of this article is to review the risk factors, diagnosis, and treatment of infectious esophagitis. RECENT FINDINGS Minimal pediatric data, including a few case reports and series, involve infectious esophagitis. Esophageal infections are usually caused by the following microbes, in order starting with the most common: Candida albicans, herpes simplex virus, and cytomegalovirus. Uncommon risk factors in these and other reports include epidural triamcinolone and oral budesonide in addition to more common risk factors such as HIV infection, chemotherapeutic agents, and transplant immunosuppressive medications. Rare reports involve immunocompetent patients and treatment of these patients is controversial. SUMMARY Understanding of infectious esophagitis is growing, and risk factors, diagnosis, and treatments are evolving.
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25
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Kagoyama K, Makino T, Ueda C, Takegami Y, Shimizu T. Detection of cytomegalovirus in the gastric ulcer of a patient with drug-induced hypersensitivity syndrome. JAAD Case Rep 2015; 1:215-8. [PMID: 27051733 PMCID: PMC4808733 DOI: 10.1016/j.jdcr.2015.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ko Kagoyama
- Department of Dermatology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Teruhiko Makino
- Department of Dermatology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Chieko Ueda
- Department of Dermatology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Yoshiaki Takegami
- Department of Dermatology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Tadamichi Shimizu
- Department of Dermatology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
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26
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İlgen U, Atmiş V, Karaarslan Cengiz Ö, Çinar E, Aras S, Varli M, Atli T. A case of CMV esophagitis complicated by extensive thrombosis in older patient without HIV infection or transplantation. Eur Geriatr Med 2015. [DOI: 10.1016/j.eurger.2015.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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