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Nakanishi T, Ishikawa K, Ohashi Y, Fujimaru T, Nobuyoshi M. Cytomegalovirus Infection of the Gastrointestinal Tract in Patients on Hemodialysis: A Case Report and Literature Review. Cureus 2024; 16:e64129. [PMID: 39119410 PMCID: PMC11307135 DOI: 10.7759/cureus.64129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/10/2024] Open
Abstract
Cytomegalovirus (CMV) infection is widespread in immunocompromised people, and several cases of CMV infections of the gastrointestinal (GI) tract have been reported in these individuals. We present a case of an immunocompetent patient on hemodialysis (HD) who developed CMV colitis. We also conducted a review of the literature on CMV GI tract infections among patients with chronic kidney disease undergoing dialysis. A 46-year-old man with a history of end-stage renal disease and undergoing HD developed severe diarrhea and hematochezia. A colonoscopy revealed ulcers, and CMV infection was identified in the biopsy sample. We successfully treated the patient with valganciclovir for 2 months. Our review of the literature yielded 21 articles and 24 cases of CMV GI tract infection in patients undergoing dialysis, including the current case. Hematochezia and diarrhea were purported to serve as indicators of CMV GI tract infection among patients on dialysis. Thus, clinicians should suspect CMV infection of the GI tract in dialysis patients, who experience unexplained bloody diarrhea, and promptly perform a GI endoscopy and biopsy.
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Affiliation(s)
| | - Kazuhiro Ishikawa
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, JPN
| | - Yusuke Ohashi
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, JPN
| | - Takuya Fujimaru
- Department of Nephrology, St. Luke's International Hospital, Tokyo, JPN
| | - Mori Nobuyoshi
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, JPN
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2
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Jagdale N, Kondapalli MP, Reddy VKK, Adapa S, Sabharwal D. An Unusual Case of an Immunocompetent Adult Diagnosed With Cytomegalovirus Colitis. Cureus 2024; 16:e58595. [PMID: 38765379 PMCID: PMC11102762 DOI: 10.7759/cureus.58595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 05/22/2024] Open
Abstract
Cytomegalovirus (CMV) infections are typically considered opportunistic in individuals with immunosuppressive conditions such as human immunodeficiency virus/acquired immunodeficiency syndrome, underlying malignancies, organ or bone marrow transplantation, and those receiving chemotherapeutics or steroids. Nevertheless, there is a significant increase in reported instances of CMV infections globally, suggesting that even individuals with a healthy immune system might experience these infections. In such cases, the primary symptoms are typically related to the gastrointestinal system, such as ulcerative colitis, pseudopolyps, tumors, and ischemic and hemorrhagic enterocolitis. We present a unique instance of severe CMV colitis in a patient with a fully functioning immune system. The diagnosis of CMV colitis was determined through the histological analysis of biopsy tissues acquired during colonoscopy.
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Affiliation(s)
- Nilesh Jagdale
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Mohith Prakash Kondapalli
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Vutukuru Kalyan Kumar Reddy
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Saimounika Adapa
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Diksha Sabharwal
- General Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
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3
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Yeh PJ, Wu RC, Chen CL, Chiu CT, Lai MW, Chen CC, Chiu CH, Pan YB, Lin WR, Le PH. Cytomegalovirus Diseases of the Gastrointestinal Tract in Immunocompetent Patients: A Narrative Review. Viruses 2024; 16:346. [PMID: 38543712 PMCID: PMC10975113 DOI: 10.3390/v16030346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/17/2024] [Accepted: 02/22/2024] [Indexed: 05/23/2024] Open
Abstract
Cytomegalovirus (CMV) is a potential pathogen that causes gastrointestinal (GI) tract diseases regardless of host immunity. In contrast to immunocompromised individuals, immunocompetent patients lack a comprehensive overview of the gastrointestinal manifestations. This study aims to provide a comprehensive summary of the current evidence regarding presentations, diagnostics, management, risk assessment, and outcomes in immunocompetent patients with CMV GI disease. A thorough literature search of English publications up to April 2022 was conducted across electronic databases to identify relevant articles, with eligible case series selected for detailed analysis. The majority of immunocompetent patients affected by CMV GI disease are typically elderly, critically ill, or burdened with comorbidities that compromise immunity. Clinical presentations range from subtle symptoms to severe surgical conditions, including instances of mortality. Specific clinical presentations, blood test results, or endoscopic features are lacking, necessitating reliance on histopathological tests such as immunohistochemistry staining for diagnosis. While antiviral therapy may offer benefits in improving outcomes, careful individual assessment is warranted due to diverse comorbidities and potential side effects. Mortality rates vary considerably based on underlying medical conditions and therapeutic approaches. It is imperative for clinicians to maintain vigilance for CMV GI disease among high-risk groups, despite their baseline immunocompetence, in order to enhance clinical outcomes.
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Affiliation(s)
- Pai-Jui Yeh
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (P.-J.Y.); (M.-W.L.); (C.-C.C.)
- Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
| | - Ren-Chin Wu
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
- Department of Pathology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
| | - Chyi-Liang Chen
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (C.-L.C.); (C.-H.C.)
| | - Cheng-Tang Chiu
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
- Department of Pathology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan 333, Taiwan
| | - Ming-Wei Lai
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (P.-J.Y.); (M.-W.L.); (C.-C.C.)
- Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
| | - Chien-Chang Chen
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (P.-J.Y.); (M.-W.L.); (C.-C.C.)
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
| | - Cheng-Hsun Chiu
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (C.-L.C.); (C.-H.C.)
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yu-Bin Pan
- Biostatistical Section, Clinical Trial Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
| | - Puo-Hsien Le
- Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan 333, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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4
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Salehi M, Shafiee N, Moradi M. Cytomegalovirus colitis in immunocompetent hosts: A case report and literature review. Clin Case Rep 2024; 12:e8435. [PMID: 38197061 PMCID: PMC10774537 DOI: 10.1002/ccr3.8435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/11/2024] Open
Abstract
Key Clinical Message Rectal bleeding can manifest cytomegalovirus (CMV) colitis even in immunocompetent patients, which can be cured with ganciclovir treatment. Abstract Cytomegalovirus (CMV) is an opportunistic virus widely affecting immunocompromised patients. Different manifestations varied from asymptomatic in immunocompetent individuals to end organ involvement, such as colitis in those with immunodeficiency. Despite the rarity of CMV colitis in immunocompetent hosts, we should consider it when the other conditions have been excluded. In this article, we have described a case of CMV colitis in an immunocompetent host and have performed a literature review on this entity. An immunocompetent 70-year-old female was admitted to the hospital with recurrent rectal bleeding. After various evaluations including laboratory analysis, stool examination, and colonoscopy, we have detected superficial lesions. Pathology and polymerase chain reaction reports favored CMV involvement. Her condition continues to improve after intravenous ganciclovir infusion. Rectal bleeding can manifest CMV colitis even in immunocompetent patients, which can be cured with ganciclovir treatment.
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Affiliation(s)
- Mohammadreza Salehi
- Department of Infectious DiseasesImam Khomeini Hospital, Tehran University of Medical SciencesTehranIran
| | - Nahid Shafiee
- Department of Infectious DiseasesImam Khomeini Hospital, Tehran University of Medical SciencesTehranIran
| | - Maryam Moradi
- Eye Research Center, The Five Senses Health InstituteRassoul Akram Hospital, Iran University of Medical SciencesTehranIran
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5
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Solito S, Vadalá di Prampero SF, Bulajic M, Battista S, Tomassini G, Panic N, Jankovic K, Marino M. Cytomegalovirus-Related Gastritis in an Immunocompetent Host Presenting With Infectious Gastroparesis. ACG Case Rep J 2023; 10:e01231. [PMID: 38107606 PMCID: PMC10723881 DOI: 10.14309/crj.0000000000001231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/14/2023] [Indexed: 12/19/2023] Open
Abstract
Cytomegalovirus (CMV) infection is usually asymptomatic or causes a mild mononucleosis-like syndrome, whereas severe symptoms are rarely reported. We report a case of a 70-year-old woman who was admitted to our center because of severe clinical presentation with anorexia, epigastric pain, nausea, postprandial vomiting, and significant weight loss. Esophagogastroduodenoscopy with biopsies showed ulcerative chronic gastritis with scattered large cells with inclusion bodies. Immunohistochemistry and polymerase chain reaction for CMV-DNA resulted positive. A gastric emptying of solid scintigraphy showed severe gastroparesis. The patient was discharged after 2 months of antiviral therapy completely asymptomatic. To the best of our knowledge, this is the first case of CMV-related gastroparesis in an immunocompetent patient, successfully treated with antiviral therapy.
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Affiliation(s)
- Sonia Solito
- Gastroenterology and GI Endoscopy Unit, Academic Medical Center of Udine, Udine, Italy
| | - Salvatore Francesco Vadalá di Prampero
- Gastroenterology and GI Endoscopy Unit, Mater Olbia Hospital, Qatar Foundation Endowment & Gemelli Foundation, Olbia, Italy
- Department for Digestive Endoscopy, Ospedale Isola Tiberina - Gemelli Isola, Rome, Italy
| | - Milutin Bulajic
- Gastroenterology and GI Endoscopy Unit, Mater Olbia Hospital, Qatar Foundation Endowment & Gemelli Foundation, Olbia, Italy
- Department for Digestive Endoscopy, Ospedale Isola Tiberina - Gemelli Isola, Rome, Italy
| | - Serena Battista
- Department of Pathology, Academic Medical Center of Udine, Udine, Italy
| | - Giulia Tomassini
- Gastroenterology and GI Endoscopy Unit, Mater Olbia Hospital, Qatar Foundation Endowment & Gemelli Foundation, Olbia, Italy
| | - Nikola Panic
- GI Endoscopy Unit, University Clinic "Dr Dragisa Misovic - Dedinje", Belgrade, Serbia
| | - Katarina Jankovic
- Clinic for Gastroenterohepatology, University Clinical Centre of Belgrade, Belgrade, Serbia
| | - Marco Marino
- Gastroenterology and GI Endoscopy Unit, Academic Medical Center of Udine, Udine, Italy
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6
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Auyeung AB, Rayan MN, Tang X, Thomas S. Radiation proctitis with recurrent gastrointestinal bleeding complicated by cytomegalovirus. J R Coll Physicians Edinb 2023; 53:265-268. [PMID: 37905373 DOI: 10.1177/14782715231205916] [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: 11/02/2023] Open
Abstract
Cytomegalovirus (CMV) usually causes infections with mild symptoms in immunocompetent individuals. However, in immunocompromised patients, these infections can be serious or life-threatening. Following initial infection, CMV typically becomes dormant but remains lifelong in the host. Reactivation of the latent virus can occur in many organ systems, including the gastrointestinal (GI) tract. Radiation proctitis is a known risk factor associated with prostate radiation, with complicating ulceration and GI bleeding. We present the first case report of an immunocompetent 81-year-old male with multiple episodes of life-threatening GI bleeding, secondary to a non-healing CMV-positive rectal ulcer and CMV colitis following radiation for prostate cancer. Multiple insults including prostate radiation, repeated blood transfusions and CMV infection likely contributed to the recurrent bleeding episodes.
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Affiliation(s)
- Austin B Auyeung
- University of Central Florida College of Medicine, Graduate Medical Education/HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL, USA
| | - Melanie N Rayan
- University of Central Florida College of Medicine, Graduate Medical Education/HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL, USA
| | - Xiaolan Tang
- University of Central Florida College of Medicine, Graduate Medical Education/HCA Florida North Florida Hospital, Internal Medicine Residency Program, Gainesville, FL, USA
| | - Sanil Thomas
- Infectious Diseases Department, HCA Florida North Florida Hospital, Gainesville, FL, USA
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7
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Matsumura S, Murao M, Ueda T, Suzuki K. Giant gastric ulcer caused by cytomegalovirus in immunocompetent adult. Dig Liver Dis 2023; 55:1436-1438. [PMID: 37516550 DOI: 10.1016/j.dld.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Shinya Matsumura
- Department of Gastroenterology, Kyoto Chubu Medical Center, Kyoto 629-0197, Japan.
| | - Moe Murao
- Department of Gastroenterology, Kyoto Chubu Medical Center, Kyoto 629-0197, Japan
| | - Tomohiro Ueda
- Department of Gastroenterology, Kyoto Chubu Medical Center, Kyoto 629-0197, Japan; Department of Gastroenterology, Kyoto Saiseikai Hospital, Kyoto 617-0845, Japan
| | - Kentaro Suzuki
- Department of Gastroenterology, Kyoto Chubu Medical Center, Kyoto 629-0197, Japan
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Turki N, Newman J, Raddaoui L, Brewer T, Alabbas B, Turki S, Younes M, Borum ML, Schueler SA. A Common Infection in a Highly Atypical Patient: Hematochezia From a Cytomegalovirus Colonic Ulcer in a Young and Healthy Immunocompetent Patient. Cureus 2023; 15:e44274. [PMID: 37772223 PMCID: PMC10530230 DOI: 10.7759/cureus.44274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 09/30/2023] Open
Abstract
Gastrointestinal (GI) cytomegalovirus (CMV) infections are far more common in immunocompromised as opposed to immunocompetent patients. Immunocompetent patients who develop GI tract CMV infections are typically older with medical comorbidities. As such, descriptions of GI CMV infections in younger immunocompetent patients are lacking. Here, we present a case of a GI CMV infection in a young and healthy immunocompetent patient. A 41-year-old male with hyperlipidemia and hypothyroidism presented with painless, intermittent hematochezia. He denied changes in bowel habits or appetite, abdominal pain, fevers, chills, fatigue, or weight loss. His history was pertinent for insertive and receptive intercourse with one male partner. Medications were emtricitabine/tenofovir for pre-exposure prophylaxis, levothyroxine, and atorvastatin. A colonoscopy revealed a cecal ulcer surrounded by nodular-appearing mucosa that felt firm and friable when biopsied. The remaining colon and terminal ileum were normal. There was no diverticulosis or hemorrhoids. Pathology was positive for CMV. A subsequent serological evaluation revealed a normal complete blood count and comprehensive metabolic panel. Tests for human immunodeficiency virus, syphilis, viral hepatitis, chlamydia, and gonorrhea were negative. He was treated with valganciclovir 900 mg twice daily for 21 days. A subsequent test for CMV deoxyribonucleic acid polymerase chain was negative. Hematochezia resolved. A repeat colonoscopy revealed normal mucosa in the cecum. GI CMV infections in immunocompetent patients are rare and typically occur in older patients with medical comorbidities. Further, such case reports are needed to inform clinicians about risk factors and the presentation of GI CMV infections in young healthy immunocompetent patients.
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Affiliation(s)
- Nouf Turki
- Gastroenterology and Hepatology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Gastroenterology and Hepatology, King Abdulaziz University Hospital, Jeddah, SAU
| | - Jacob Newman
- Internal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Leen Raddaoui
- Division of Gastroenterology and Liver Diseases, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Taylor Brewer
- Internal Medicine, George Washington University, Washington, DC, USA
| | - Bedoor Alabbas
- Gastroenterology and Hepatology, Sinai Hospital of Baltimore, Baltimore, USA
| | - Sarah Turki
- Internal Medicine, George Washington University, Washington, DC, USA
| | - Mamoun Younes
- Pathology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Marie L Borum
- Division of Gastroenterology and Liver Diseases, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Samuel A Schueler
- Gastroenterology and Hepatology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Kawata S, Takamatsu J, Yasue Y, Fukuhara A, Kang J. Cytomegalovirus enteritis resistant to antiviral drugs improved following total colectomy. Surg Case Rep 2023; 9:109. [PMID: 37318698 DOI: 10.1186/s40792-023-01672-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/15/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection, often subclinical in childhood, is reactivated during a state of cell-mediated immunodeficiency. In cases of organ damage, patients can require medical treatment for an infectious disease, generally through the use of antiviral drugs. There are no reports of surgical treatment in cases, where infection was found, and medical treatment was difficult. We encountered a case of CMV enteritis that was difficult to treat because of resistance to antivirals but improved after total colectomy. CASE PRESENTATION A previously healthy, 74-year-old woman visited a doctor with a chief complaint of watery diarrhea persisting for 2 weeks; she was transferred to our hospital because of hypoxemia and hypovolemic shock. Computed tomography scan indicated wall thickening over the entire colon and the patient was diagnosed with infectious colitis. Conservative and antibacterial therapies were started with fasting fluid replacement. Subsequently, bloody stools were observed 11 days after admission. Colonoscopy was then performed, which showed mucosal edema and longitudinal ulcer, while a histopathological examination of the colon mucosa revealed C7HRP positive on 22 days after admission. CMV enteritis was diagnosed, and the antiviral medication, ganciclovir, was started. Diseases causing immunosuppression and other possible causes of enteritis were also closely examined; however, all were negative. Furthermore, the patient's symptoms and her endoscopic findings did not improve with ganciclovir administration; therefore, the antiviral drug was changed to foscarnet. Unfortunately, the patient did not improve despite the additional administration of gamma globulin and methylprednisolone, and she was determined to have enteritis resistant to medical therapy. A total colon resection was performed 88 days after the admission. Her condition gradually stabilized postoperatively, and oral intake was initiated and tolerated. The patient was transferred to another hospital for rehabilitation for home discharge. She is now at home and has had no recurrences. CONCLUSIONS In previous reports of surgical treatment for CMV enteritis, many cases were initially undiagnosed, emergency surgery was performed after perforation or stenosis was recognized, and then CMV was diagnosed and treated. In CMV enteritis without immunodeficiency, surgical treatment may be an option if medical treatment is ineffective.
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Affiliation(s)
- Sae Kawata
- Department of Emergency Medicine, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-0064, Japan.
| | - Jumpei Takamatsu
- Department of Emergency Medicine, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-0064, Japan
| | - Yuichi Yasue
- Department of Emergency Medicine, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-0064, Japan
| | - Aya Fukuhara
- Department of Emergency Medicine, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-0064, Japan
| | - Jinkoo Kang
- Department of Emergency Medicine, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-0064, Japan
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Sattayalertyanyong O, Limsrivilai J, Phaophu P, Subdee N, Horthongkham N, Pongpaibul A, Angkathunyakul N, Chayakulkeeree M, Pausawasdi N, Charatcharoenwitthaya P. Performance of Cytomegalovirus Real-Time Polymerase Chain Reaction Assays of Fecal and Plasma Specimens for Diagnosing Cytomegalovirus Colitis. Clin Transl Gastroenterol 2023; 14:e00574. [PMID: 36854054 PMCID: PMC10208703 DOI: 10.14309/ctg.0000000000000574] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/09/2023] [Indexed: 03/02/2023] Open
Abstract
INTRODUCTION Cytomegalovirus (CMV) viral load detected by real-time polymerase chain reaction (PCR) in plasma or stool may facilitate detection of CMV colitis. METHODS This prospective study enrolled 117 patients with clinically suspected CMV colitis. Patients presenting with gastrointestinal symptoms and having increased risk of CMV infection were eligible. All participants underwent colonoscopy with tissue biopsy. Five patients underwent colonoscopy twice because of clinical recurrence, resulting in a total of 122 colonoscopies. Stool CMV-PCR and plasma CMV-PCR were performed within 7 days before/after colonoscopy. Twenty asymptomatic volunteers also underwent the same protocol. RESULTS Twenty-seven (23.1%) of 122 colonoscopies yielded positive for CMV colitis. The sensitivity and specificity was 70.4% and 91.6% for stool CMV-PCR and 66.7% and 94.7% for plasma CMV-PCR, respectively. The sensitivity of either positive plasma or positive stool CMV-PCR was 81.5%, which is significantly higher than that of plasma CMV-PCR alone ( P = 0.045). However, positive results from both tests yielded a specificity of 95.8%, which is significantly higher than that of stool CMV-PCR alone ( P = 0.045). There was a good and significant correlation between stool CMV-PCR and plasma CMV-PCR ( r = 0.71, P < 0.01), and both tests significantly correlated with the cytomegalic cell count ( r = 0.62, P < 0.01 for stool and r = 0.64, P < 0.01 for plasma). There were no positive stool or plasma CMV-PCR assays among volunteers. DISCUSSION The results of this study strongly suggest that the combination of stool CMV-PCR and plasma CMV-PCR can be used to confidently rule in (both positive) or rule out (both negative) a diagnosis of CMV colitis.
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Affiliation(s)
- Onuma Sattayalertyanyong
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
| | - Julajak Limsrivilai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
| | - Phutthaphorn Phaophu
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
| | - Nichcha Subdee
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
| | - Navin Horthongkham
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
| | - Ananya Pongpaibul
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
| | - Napat Angkathunyakul
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Nonthalee Pausawasdi
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
| | - Phunchai Charatcharoenwitthaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand;
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11
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Lagarto M, Santos A, Freitas BD, Anastácio M, Jesus S. The Overlooked Agent: Cytomegalovirus Colitis in an Immunocompetent Patient. Cureus 2023; 15:e36926. [PMID: 37128542 PMCID: PMC10148746 DOI: 10.7759/cureus.36926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/03/2023] Open
Abstract
Cytomegalovirus (CMV) colitis is usually associated with immunosuppressed patients, which by the classic definition are individuals who have immunosuppressed associated conditions (human immunodeficiency virus [HIV], oncology diseases, inflammatory bowel disease, transplant patients) or who are submitted to immunosuppressing therapies (for instance, corticosteroids, chemotherapeutic agents or immunomodulation therapies). In immunocompetent patients, this diagnosis tends to be often missed, leading to a delay in initiating proper management. We present a case of a 91-year-old woman that was diagnosed with CMV colitis without any identified formal immunocompromising factors. We intend to highlight the need to review the definition of an immunosuppressed individual and emphasize that CMV colitis should be considered in the differential diagnosis, especially in elderly patients and those with underlying conditions that can possibly affect their immune status, since prompt diagnosis and treatment are essential and influence the prognosis.
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Affiliation(s)
- Margarida Lagarto
- Medical Oncology, Centro Hospitalar de Lisboa Ocidental, Lisboa, PRT
| | - Ana Santos
- Internal Medicine, Centro Hospitalar de Lisboa Ocidental, Lisboa, PRT
| | - Bruno D Freitas
- Internal Medicine, Centro Hospitalar de Lisboa Ocidental, Lisboa, PRT
| | - Marta Anastácio
- Internal Medicine, Centro Hospitalar de Lisboa Ocidental, Lisboa, PRT
| | - Susana Jesus
- Internal Medicine, Centro Hospitalar de Lisboa Ocidental, Lisboa, PRT
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12
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Jagirdhar GSK, Surani S. Non-clostridium difficile induced pseudomembranous colitis. World J Clin Cases 2023; 11:979-988. [PMID: 36874439 PMCID: PMC9979294 DOI: 10.12998/wjcc.v11.i5.979] [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: 11/02/2022] [Revised: 01/09/2023] [Accepted: 01/20/2023] [Indexed: 02/14/2023] Open
Abstract
Pseudomembranous colitis is severe inflammation of the inner lining of the colon due to anoxia, ischemia, endothelial damage, and toxin production. The majority of cases of pseudomembranous colitis are due to Clostridium difficile. However, other causative pathogens and agents have been responsible for causing a similar pattern of injury to the bowel with the endoscopic appearance of yellow-white plaques and membranes on the mucosal surface of the colon. Common presenting symptoms and signs include crampy abdominal pain, nausea, watery diarrhea that can progress to bloody diarrhea, fever, leukocytosis, and dehydration. Negative testing for Clostridium difficile or failure to improve on treatment should prompt evaluation for other causes of pseudomembranous colitis. Bacterial infections other than Clostridium difficile, Viruses such as cytomegalovirus, parasitic infections, medications, drugs, chemicals, inflammatory diseases, and ischemia are other differential diagnoses to look out for in pseudomembranous colitis. Complications of pseudomembranous colitis include toxic megacolon, hypotension, colonic perforation with peritonitis, and septic shock with organ failure. Early diagnosis and treatment to prevent progression are important. The central perspective of this paper is to provide a concise review of the various etiologies for pseudomembranous colitis and management per prior literature.
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Affiliation(s)
| | - Salim Surani
- Department of Pulmonary, Critical Care & Pharmacy, Texas A&M University, Kingsville, TX 78363, United States
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13
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Gu J, Ji H, Liu T, Chen C, Zhao S, Cao Y, Wang N, Xiao M, Chen L, Cai H. Detection of cytomegalovirus (CMV) by digital PCR in stool samples for the non-invasive diagnosis of CMV gastroenteritis. Virol J 2022; 19:183. [DOI: 10.1186/s12985-022-01913-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
CMV gastroenteritis is common in patients receiving allogeneic hematopoietic stem cell transplantation and it is difficult to distinguish from acute graft-versus-host disease (aGvHD), which has very similar symptoms but needs quite different treatment. CMV gastroenteritis is caused by local infection or reactivation of CMV in the gastrointestinal tract while aGvHD is due to immune rejection. The gold standard of diagnosis of CMV gastroenteritis and aGvHD is gastrointestinal biopsy under endoscopy, which is invasive and can potentially lead to severe side effects. Stool samples testing with quantitative polymerase chain reaction (qPCR) may be an alternative, while the application in trace level measurements and precision are not all satisfactory enough in reported research.
Methods
In this study, we designed a novel method that extracted the cell free DNA (cfDNA) from the fecal supernatant to perform digital PCR (dPCR) for the detection of CMV, analyzed the performance and compared it with the total DNA extracted by the current procedure.
Results
Twenty-two paired stool samples using two DNA extraction methods proved that the cfDNA extraction method had markedly higher DNA concentrations and control gene copy number, suggesting that cfDNA may be more informative and more useful for the detection of CMV DNA segment. The dPCR approach in detecting CMV DNA segment also exhibit good linearity (R2 = 0.997) and higher sensitivity (limit of detection at 50% was 3.534 copies/μL). Eighty-two stool samples from 44 immunocompromised patients were analyzed, CMV-positive rate was 28%, indicating that more than one-quarter of the gastrointestinal symptoms within these patients may be caused by CMV infection or reactivation.
Conclusion
The combined results suggest that detection of CMV by dPCR in cfDNA of stool supernatant is a powerful method to identify CMV gastroenteritis and helps in clinical treatment decision making.
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14
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King W, Richhart R, Hernandez Gonzalo D, Zimmerman E. Cytomegaloviral colitis in primary CMV viraemia in a young immunocompetent adult. BMJ Case Rep 2022; 15:e249891. [PMID: 36220260 PMCID: PMC9557276 DOI: 10.1136/bcr-2022-249891] [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: 06/16/2023] Open
Abstract
A man in his 20s presented with a 2-week history of fever, fatigue and diarrhoea. On arrival to the emergency department, he had clinical findings of sepsis. The care team initially suspected sepsis secondary to bacterial colitis and administered antibiotics. Further workup including a stool PCR assay for gastrointestinal pathogens failed to establish a diagnosis, and he had no evidence of immune compromise. Colonoscopy revealed mucosal ulceration presumed to be ulcerative colitis. Histopathology obtained after discharge revealed severe colitis with cytomegalovirus (CMV) inclusions. Serological studies indicated a primary CMV infection. To our knowledge, this is the first report of a primary CMV infection presenting as severe colitis and systemic disease in a young immunocompetent patient without underlying disease.
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Affiliation(s)
- William King
- Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Raymond Richhart
- Internal Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Ellen Zimmerman
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL, USA
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15
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Hill M, Obeng-Gyasi E. The Association of Cytomegalovirus IgM and Allostatic Load. Diseases 2022; 10:diseases10040070. [PMID: 36278569 PMCID: PMC9590072 DOI: 10.3390/diseases10040070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/21/2022] [Accepted: 09/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Cytomegalovirus (CMV) is a deoxyribonucleic acid virus that affects a significant proportion of the worldwide population; after primary infection, it goes into a latent state and can be reactivated, primarily after a reduction in host immune defenses. Methods: This study evaluated the association of acute cytomegalovirus infection (CMV IgM) and Allostatic Load (AL) by sociodemographic factors using data from the National Health and Nutrition Examination Survey (NHANES) 2001–2004 among participants (aged 20–49 years). CMV infection was determined by the level of CMV IgM antibody in serum samples. AL was assessed as a combination of 10 biomarkers from the cardiovascular, inflammatory, and metabolic systems. The evaluation of the association between CMV infection and AL included descriptive statistics and logistic regression models, which were adjusted for demographic and behavioral covariates. Results: AL was more elevated among those who were older, male, those with lower education, those performing limited physical activity, and smokers. CMV was more elevated in females than males among those who consumed alcohol and cigarette smokers. In Pearson’s correlation analysis, there was a slight positive correlation between CMV IgM and AL, with triglycerides and Body Mass Index (BMI) the most strongly correlated with AL. Binary logistic regression showed no significant relationship between high AL and positive CMV IgM but did show a significant relationship between high AL and age (OR = 1.0592, 95% CI 1.0215–1.0983, p = 0.00715). The findings of this study provide insight into the relationship between CMV and AL and provide awareness of factors that affect their relationship.
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Affiliation(s)
- Matthew Hill
- Department of Built Environment, North Carolina A&T State University, Greensboro, NC 27411, USA
- Environmental Health and Disease Laboratory, North Carolina A&T State University, Greensboro, NC 27411, USA
| | - Emmanuel Obeng-Gyasi
- Department of Built Environment, North Carolina A&T State University, Greensboro, NC 27411, USA
- Environmental Health and Disease Laboratory, North Carolina A&T State University, Greensboro, NC 27411, USA
- Correspondence: ; Tel.: +1-336-285-3132
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16
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CMV Colitis Masquerading as MALT Lymphoma in an Immunocompetent Patient. ACG Case Rep J 2022; 9:e00851. [PMID: 36072358 PMCID: PMC9439750 DOI: 10.14309/crj.0000000000000851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 05/31/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022] Open
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17
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Kwon J, Fluxá D, Farraye FA, Kröner PT. Cytomegalovirus-related colitis in patients with inflammatory bowel disease. Int J Colorectal Dis 2022; 37:685-691. [PMID: 35132443 DOI: 10.1007/s00384-022-04099-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE We aimed to examine the role of cytomegalovirus (CMV) infection in patients with inflammatory bowel disease (IBD), which remains highly debated. METHODS Retrospective, observational study using the Nationwide Inpatient Sample (NIS) 2015-2017. Patients with ICD9/10CM codes for Crohn's disease (CD), ulcerative colitis (UC), and CMV colitis were included in the study. The primary outcome was the odds of CMV colitis in patients with IBD compared to patients without IBD. Secondary outcomes were differences in inpatient morbidity, mortality, resource utilization, colectomy rates, hospital length of stay (LOS), and inflation-adjusted total hospitalization costs. RESULTS A total of 992,445 patients with IBD were identified, out of which 520 (0.05%) had associated CMV colitis. Patients with IBD had significantly higher odds of CMV colitis compared to patients without IBD (aOR: 19.76, p < 0.01), having an even greater association with UC (aOR: 31.13, p < 0.01). CMV colitis in patients with CD was associated with a significant increase in odds of mortality, shock, and ICU stay, while patients with UC had higher odds of colectomy. The patients with IBD and CMV colitis had higher odds of acute kidney injury, multiorgan failure, markedly increased additional hospital costs, and LOS compared to patients with IBD and no CMV colitis. CONCLUSION IBD has a significant association with CMV colitis, and the presence of CMV colitis in patients with IBD was associated with higher mortality, morbidity, and hospital costs. Prospectively designed studies may better elucidate the risk factors and impact of CMV colitis on patients with IBD.
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Affiliation(s)
- Joshua Kwon
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA.
| | - Daniela Fluxá
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Paul T Kröner
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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18
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Jung KH, Jung J, Kim MJ, Chong YP, Lee SO, Choi SH, Kim YS, Kim SH. Optimal duration of antiviral treatment in patients with gastrointestinal cytomegalovirus disease at a low and high risk of relapse. Medicine (Baltimore) 2022; 101:e28359. [PMID: 35029881 PMCID: PMC8735784 DOI: 10.1097/md.0000000000028359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022] Open
Abstract
We evaluated the association between antiviral treatment duration and relapse of gastrointestinal (GI) cytomegalovirus (CMV) disease by analyzing the risk factors for relapse.Patients who were diagnosed with GI CMV disease at a tertiary hospital from January 2008 to April 2019 were retrospectively enrolled. Patients with relapsed disease were those with a recurrence of GI CMV disease at least 4 weeks after the initial antiviral treatment.Of 238 participants, including 145 (51.9%) with upper and 93 (48.1%) with lower GI CMV diseases, 27 (11.3%) had experienced relapses. The difference in antiviral treatment duration between the relapsed and nonrelapsed GI CMV groups was not significant (median days, 21.0 vs 17.0, P = .13). Multivariate analysis revealed that hematologic malignancy (odds ratio, 3.73; P = .026) and ulcerative colitis (odds ratio, 4.61; P = .003) were independent risk factors for relapse. Participants with at least one of these risk factors and those with no independent risk factors were classified under the high- (relapse rate, 25.9%) and low-risk of relapse groups (relapse rate, 6.7%), respectively. Accordingly, we further stratified 180 (75.6%) and 58 (24.4%) participants under the low- and high-risk of relapse groups, respectively. There was no significant difference in relapse rates between the high- and low-risk groups according to antiviral treatment duration.Approximately 10% of the participants experienced relapses after antiviral treatment, with hematologic malignancy and ulcerative colitis featuring as risk factors. Therefore, prolonged antiviral treatment might not be helpful in preventing GI CMV disease relapse.
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Affiliation(s)
- Kyung Hwa Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Infectious Diseases, Uijeongbu Eulji Medical Center, University of Eulji College of Medicine, Uijeongbu, Republic of Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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19
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Ihara K, Isono H, Isono M, Akaiwa Y, Kobayashi K, Oogi M, Oogi T. Cytomegalovirus colitis with a new diagnosis of ulcerative colitis in an elderly woman. J Rural Med 2022; 17:85-88. [PMID: 35432635 PMCID: PMC8984622 DOI: 10.2185/jrm.2021-053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/12/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives: Cytomegalovirus (CMV) colitis is generally diagnosed in
immunocompromised patients. It is rare for patients who are not immunocompromised to
develop CMV colitis. Cases of CMV colitis in patients with inflammatory bowel disease have
also been reported. We encountered a case of CMV colitis with a new diagnosis of severe
ulcerative colitis and demonstrated the importance of suspecting ulcerative colitis in
immunocompetent patients with CMV colitis. Patient: A 78-year-old woman was hospitalized with fever and diarrhea that
had lasted for a month. Colonoscopy revealed continuous diffuse edema, mucosal redness,
and multiple punched-out ulcers with bleeding, suggesting cytomegalovirus (CMV) colitis,
although she was not immunocompromised. Immunohistochemical staining revealed CMV-positive
cells, and CMV colitis was diagnosed. One month later, a colonoscopy was conducted owing
to persistent symptoms despite initiating the prescribed antiviral drug. A complete loss
of vascular pattern, easy bleeding of the crude mucosa, and exacerbation of multiple
punched-out ulcers were observed. She was diagnosed with severe ulcerative colitis. The
symptoms of ulcerative colitis disappeared with prednisolone and 5-amino salicylic acid
treatment. Conclusion: Ulcerative colitis should be suspected in immunocompetent
patients with CMV colitis.
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Affiliation(s)
- Kousuke Ihara
- Department of General Medicine, HITO Medical Center, Ehime, Japan
| | - Hiroki Isono
- Department of General Medicine, HITO Medical Center, Ehime, Japan
| | - Momoko Isono
- Department of General Medicine, HITO Medical Center, Ehime, Japan
| | - Yuzuru Akaiwa
- Department of Internal Medicine, HITO Medical Center, Ehime, Japan
| | | | - Maki Oogi
- Department of Internal Medicine, HITO Medical Center, Ehime, Japan
| | - Tomohiro Oogi
- Department of Internal Medicine, HITO Medical Center, Ehime, Japan
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20
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A Rare Case of Cytomegalovirus and Herpes Simplex Virus Coinfection Gastritis and Colitis in a Person Living With HIV/AIDS. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021. [DOI: 10.1097/ipc.0000000000001077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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CMV-Related Gastric Ulcer and Gastroduodenitis in an Immunocompetent Patient: A Case Report and Literature Review. Case Rep Gastrointest Med 2021; 2021:3513223. [PMID: 34804617 PMCID: PMC8604585 DOI: 10.1155/2021/3513223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 10/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background Cytomegalovirus (CMV)- related gastroduodenal infection is rare in immunocompetent hosts, and although it is considered a self-limiting condition in most cases, there is scarce literature to assert its management. Case Presentation. We report a case of a 66-year-old immunocompetent male patient diagnosed with a giant gastric ulcer caused by CMV infection. The ulcer manifested as refractory vomiting and melena. Rapid and full resolution was observed on proton-pump inhibitor (PPI) monotherapy. Conclusion Gastric CMV infection might mimic an advanced gastric tumor in individuals with an intact immune system. The condition is rare, and the diagnosis is challenging and oftentimes overlooked. However, a rapid resolution has been documented in all cases, even without antiviral therapy.
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22
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Liu KY, Chao HM, Lu YJ, Su YS, Lee WS. Cytomegalovirus proctitis in non-human immunodeficiency virus infected patients: A case report and literature review. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 55:154-160. [PMID: 34764027 DOI: 10.1016/j.jmii.2021.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 10/12/2021] [Accepted: 10/16/2021] [Indexed: 02/06/2023]
Abstract
Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in both immunocompetent and immunocompromised patients. CMV is a ubiquitous Herpesviridae virus with a wide spectrum of pathologies in humans. Immunocompetent patients generally develop a benign, self-limited mononucleosis-like syndrome, whereas gastrointestinal tissue-invasive disease is more frequently seen in immunocompromised. The clinical manifestations of CMV colitis or proctitis are demarcated by bloody diarrhea, ulcerations, ulcero-infiltrative changes, and pseudomembranous formation on colonoscopy. Gastrointestinal CMV infections complicated with deep rectal ulcer and fistula formation are rare in patients with systemic lupus erythematosus. Ganciclovir is also the gold standard therapy for CMV colitis or proctitis.
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Affiliation(s)
- Kai-Yuan Liu
- Department of Surgery, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
| | - Hsiao-Mei Chao
- Department of Pathology, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
| | - Yen-Jung Lu
- Division of Colorectal Surgery, Department of Surgery, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
| | - Ying-Shih Su
- Division of Infectious Diseases, Department of Internal Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
| | - Wen-Sen Lee
- Division of Infectious Diseases, Department of Internal Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Kim BS, Park SY, Kim DH, Kim NI, Yoon JH, Ju JK, Park CH, Kim HS, Choi SK. Cytomegalovirus colitis induced segmental colonic hypoganglionosis in an immunocompetent patient: A case report. World J Clin Cases 2021; 9:5631-5636. [PMID: 34307618 PMCID: PMC8281438 DOI: 10.12998/wjcc.v9.i20.5631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/02/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) colitis is usually seen in immunocompromised patients with risk factors such as human immunodeficiency virus infection, solid organ transplant, inflammatory bowel disease, or malignancy. Therefore, many clinicians usually do not consider the possibility of CMV colitis in immunocompetent patients. We reported a rare case of segmental colonic hypoganglionosis associated with CMV colitis in an immunocompetent patient.
CASE SUMMARY A 48-year-old woman with no underlying disease was admitted to our hospital for severe abdominal pain and constipation. Computed tomography of the abdomen showed diffuse dilatation of the small intestine and the entire colon. Initial sigmoidoscopic findings and result of polymerase chain reaction (PCR) for CMV revealed the compatible findings of CMV colitis, the patient was treated with intravenous ganciclovir. After treatment, sigmoidoscopic findings and CMV PCR results improved. However the patient continued to suffered from constipation. Eight months after the initial admission, patient visited the emergency department with severe abdominal pain and imaging revealed aggravation of fecal impaction and bowel dilatation. We performed subtotal colectomy to control patient’s symptom. Histological examination of the resected specimen showed significantly reduced number of mature ganglion cells in the sigmoid colon compared to that in the proximal colon.
CONCLUSION Our case demonstrates that CMV colitis can develop even in patients with no other underlying disease, and that CMV colitis can be one of the causes for developing colonic hypoganglionosis.
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Affiliation(s)
- Ban Seok Kim
- Department of Gastroenterology, Chonnam National University Hospital, Gwangju 501-757, South Korea
| | - Seon-Young Park
- Department of Gastroenterology, Chonnam National University Hospital, Gwangju 501-757, South Korea
| | - Dong Hyun Kim
- Department of Gastroenterology, Chonnam National University Hospital, Gwangju 501-757, South Korea
| | - Nah Ihm Kim
- Department of Pathology, Chonnam National University Hospital, Gwangju 501-757, South Korea
| | - Jae Hyun Yoon
- Department of Gastroenterology, Chonnam National University Hospital, Gwangju 501-757, South Korea
| | - Jae Kyun Ju
- Department of Surgery, Chonnam University Hospital, Gwangju 501-757, South Korea
| | - Chang Hwan Park
- Department of Gastroenterology, Chonnam National University Hospital, Gwangju 501-757, South Korea
| | - Hyun Soo Kim
- Department of Gastroenterology, Chonnam National University Hospital, Gwangju 501-757, South Korea
| | - Sung Kyu Choi
- Department of Gastroenterology, Chonnam National University Hospital, Gwangju 501-757, South Korea
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24
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Yeh PJ, Chiu CT, Lai MW, Wu RC, Kuo CJ, Hsu JT, Su MY, Le PH. Cytomegalovirus gastritis: Clinicopathological profile. Dig Liver Dis 2021; 53:722-728. [PMID: 33441265 DOI: 10.1016/j.dld.2020.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/02/2020] [Accepted: 12/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) gastritis is occasionally reported in case reports and limited case series. Up to now, it is the largest and most comprehensive retrospective study of CMV gastritis. METHODS All patients who were histologically diagnosed with CMV gastritis at Linkou Chang Gung Memorial Hospital between January 2000 and April 2020 were included. Patients were divided into two groups according to immunity. Between-group differences in characteristics, manifestations, endoscopic features, prognostic factors, and outcomes were analyzed. The main endpoint was 3-month mortality. RESULTS A total of 54 patients (34 immunocompromised, 20 immunocompetent) were enrolled. Common presentations included gastrointestinal bleeding (35.2%), abdominal pain (33.3%) and fever (31.5%). The endoscopic features included ulcer (88.9%) and inflammation (11.1%). The 3-month mortality rate was 20.4% and overall mortality rate was 40.7%. Acute kidney injury was the only independent risk factor for 3-month mortality (OR 53.89, 95%CI 1.56-1861.73, p = 0.027). Anti-viral therapy and host immune status did not affect 3-month mortality. CONCLUSION Both immunocompromised and immunocompetent patients with CMV gastritis have high mortality rates, without significant between-group differences. Acute kidney injury is the only independent predictive factor for 3-month mortality. Prevention of acute kidney injury may possibly improve the 3-month mortality rate.
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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 Branch5, Fu-Hsin Street, Guei-Shan District, Taoyuan City, Taoyuan, Taiwan; Taiwan Association of the Study of Small Intestinal Disease, 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, Taiwan; Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taiwan
| | - Ren-Chin Wu
- Department of Pathology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chia-Jung Kuo
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch5, Fu-Hsin Street, Guei-Shan District, Taoyuan City, Taoyuan, Taiwan; Taiwan Association of the Study of Small Intestinal Disease, 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, Taiwan; Department of Gastroenterology and Hepatology, New Taipei City Municipal Tucheng Hospital (Chang Gung Memorial Hospital), Tucheng branch, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch5, Fu-Hsin Street, Guei-Shan District, Taoyuan City, Taoyuan, Taiwan; Taiwan Association of the Study of Small Intestinal Disease, Taiwan; Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taiwan.
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25
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Clinical Features, Endoscopic Findings, and Predictive Factors for Mortality in Tissue-Invasive Gastrointestinal Cytomegalovirus Disease between Immunocompetent and Immunocompromised Patients. Gastroenterol Res Pract 2021; 2021:8886525. [PMID: 33897776 PMCID: PMC8052155 DOI: 10.1155/2021/8886525] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 03/19/2021] [Accepted: 03/27/2021] [Indexed: 12/26/2022] Open
Abstract
Background and Aims Tissue-invasive gastrointestinal cytomegalovirus (TI-GI CMV) disease is common in immunocompromised patients, but the increasing prevalence in immunocompetent patients has been reported. This study compared the clinical manifestations, endoscopic features, treatment outcomes, and predictors for inhospital mortality of TI-GI CMV between immunocompromised and immunocompetent patients. Methods Patients with HIV infection, malignancy, or receiving immunosuppressive agents (chemotherapy, high dose, or long-term corticosteroids) were defined as the immunocompromised group. Demographic and inhospital mortality data were obtained and retrospectively analyzed. Results A total of 213 patients (89 immunocompetent) with histologically confirmed TI-GI CMV were enrolled. Immunocompetent patients were older (70 vs. 52 years; p < 0.001), had more GI bleeding as a presenting symptom (47.2% vs. 29.0%; p = 0.010), and shorter symptom onset (2 vs. 14 days, p = 0.018). Concomitant extra-GI involvement was only seen in the immunocompromised group (6.5% vs. 0%; p = 0.02). Diffuse GI tract (14.5% vs. 4.5%; p = 0.032) and esophageal involvement (14.5% vs. 5.6%; p = 0.046) were more frequent in the immunocompromised, while small bowel involvement was more frequent in the immunocompetent group (19.1% vs. 8.1%; p = 0.029). An overall inhospital mortality was 27.7%. There was no significant difference in inhospital survival probability between the two groups (Peto-Peto test, p = 0.65). ICU admission (hazard ratio [HR] 7.21; 95% CI 2.55-20.36), sepsis or shock (HR 1.98; 95% CI 1.08-3.66), malnutrition (HR 2.62; 95% CI 1.05-7.01), and receiving chemotherapy (HR 5.2; 95% CI 1.89-14.29) were independent factors for inhospital mortality. Antiviral treatment for more than 14 days was the only protective factor to improve survival (Peto-Peto test, p < 0.001). Conclusions Immunocompetent and immunocompromised patients with TI-GI CMV disease had distinct clinical and endoscopic characteristics. There was no significant difference in the inhospital mortality between the two groups. The factors for mortality were ICU admission, sepsis/shock, malnutrition, and receiving chemotherapy. Early diagnosis and initiation of antiviral treatment might improve the survival probability.
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Ochiai Y, Hoteya S, Kono K, Takazawa Y, Matsui A, Kikuchi D. Cytomegalovirus ileitis with protein-losing enteropathy in an immunocompetent adult. Clin J Gastroenterol 2021; 14:1060-1066. [PMID: 33745065 DOI: 10.1007/s12328-021-01382-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Abstract
Symptomatic cytomegalovirus (CMV) infection in immunocompetent hosts has traditionally been considered to have a benign, self-limited course, and those who need intensive therapy are rare. Moreover, there are few reports of CMV infection with protein-losing enteropathy (PLE). We present an immunocompetent 74-year-old woman with CMV ileitis with PLE, which was diagnosed due to severe hypoalbuminemia and edema of the lower extremities. The patient was not immunocompromised, because a human immunodeficiency virus (HIV) antibody test was negative and she had not been taking immunosuppressants. Imaging tests including colonoscopy revealed ileitis with shallow widespread ulcers. 99mTc-human serum albumin (HAS-D) scintigraphy suggested a possibility of protein loss in the ileum based on selective accumulation of nuclides in the right abdomen. Histological findings of the biopsy showed ulcerative mucosa with abnormal cells, which had enlarged nuclei with intranuclear inclusion bodies, including typical Cowdry A type. In immunohistochemistry, these cells were positive for anti-CMV staining. She was successfully treated with medical treatments including intravenous injection of ganciclovir (GCV) (500 mg/day). We described an extremely rare case of CMV ileitis with PLE in an immunocompetent adult who was treated successfully with medical treatments, including GCV.
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Affiliation(s)
- Yorinari Ochiai
- Department of Gastroenterology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
| | - Shu Hoteya
- Department of Gastroenterology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Kei Kono
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | | | - Akira Matsui
- Department of Gastroenterology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Daisuke Kikuchi
- Department of Gastroenterology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
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Endoscopic features and clinical outcomes of cytomegalovirus gastroenterocolitis in immunocompetent patients. Sci Rep 2021; 11:6284. [PMID: 33737711 PMCID: PMC7973552 DOI: 10.1038/s41598-021-85845-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/05/2021] [Indexed: 01/15/2023] Open
Abstract
We aimed to investigate the endoscopic features and clinical course of CMV gastroenterocolitis in immunocompetent patients. We reviewed the medical records and endoscopic images of 86 immunocompetent patients with CMV gastroenterocolitis. Immunocompetent patients were defined as those without congenital or acquired immunodeficiency syndrome, use of anti-cancer chemotherapeutic and immunosuppressive agents, and inflammatory bowel diseases. The mean age was 65.5 ± 11.8 years and 53 (61.6%) were male. Sixty-eight (79.1%) patients had comorbidities. Upper gastrointestinal-dominant, small bowel-dominant, and colon-dominant types were observed in 19, 7, and 60 patients, respectively. Endoscopic features could be classified into discrete ulcerative type with/without exudate and diffuse erythematous type with/without exudate. Antiviral treatment with ganciclovir was initiated in 51 patients (59.3%), 40 of whom improved and 1 improved after changing ganciclovir to foscarnet. Thirty-three patients (38.4%) improved without antiviral treatment. Surgery was necessary in two patients because of colon perforation before antiviral treatment. Another two patients underwent surgery because of sigmoid stricture and cecal perforation during antiviral treatment. Endoscopic type was not associated with clinical outcomes, such as surgery and death. CMV gastroenterocolitis in immunocompetent patients mostly occur in older patients with comorbidities, and the endoscopic features vary with no association with clinical outcomes.
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Surapaneni BK, Priyadarshni S, Choksi V, Sorathia S, Kasmin F. A Rare Case of Cytomegalovirus in the Gut in an Immunocompetent Host With Ischemic Colitis. Cureus 2020; 12:e9432. [PMID: 32742891 PMCID: PMC7389188 DOI: 10.7759/cureus.9432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Cytomegalovirus (CMV) infections are typically seen in individuals with immunosuppressive conditions such as malignancies, HIV/AIDS, and organ transplantation, and in patients on chemotherapy or steroids. Recurrent disease can occur if the virus reactivates due to disruption of immunity due to factors such as older age or immunosuppressive drugs. CMV is common, with a seroprevalence (CMV IgG-positive) of 40-100 % in adults, increasing with age. It has been reported that inflammatory bowel disease in remission can be exacerbated by CMV colitis or complicate steroids refractory colitis flare. For this reason, steroids should be cautiously started if clinical suspicion is high for CMV. We report a unique case of CMV colitis associated with severe ischemic colitis in an immunocompetent patient, with an excellent response to management with antiviral therapy.
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Zahid M, Ali N, Saad M, Kelly P, Ortiz A. Acute Cytomegalovirus (CMV) Hepatitis in an Immunocompetent Adult. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925495. [PMID: 32673293 PMCID: PMC7387041 DOI: 10.12659/ajcr.925495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a member of Herpesviridae family with its name derived from the fact that it causes enlargement of the infected cell resulting in the characteristic inclusion bodies seen on microscopy. CMV virus has an incubation period of about 4 to 6 weeks. Symptoms of CMV infection vary and depend on factors including the age and immune status of the patient. It usually presents as asymptomatic infection in immunocompetent individuals whereas severe disease is usually seen in immunocompromised patients. Here we present a case of an immunocompetent patient who presented with acute CMV hepatitis. CASE REPORT A 35-year-old male with no significant prior medical history who presented to the Emergency Department with a 2-week history of low-grade fever. Acute CMV infection was diagnosed by positive CMV antibody and polymerase chain reaction (PCR) testing. The patient was treated with valganciclovir that resulted in rapid improvement in clinical status as well as normalization of the liver enzymes. CONCLUSIONS This article presents a rare case of immunocompetent young male with acute CMV hepatitis who responded favorably to antiviral therapy.
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Affiliation(s)
- Maleeha Zahid
- Department of Internal Medicine, Bronx Care Health System, Bronx, NY, USA
| | - Nisha Ali
- Department of Internal Medicine, Bronx Care Health System, Bronx, NY, USA
| | - Muhammad Saad
- Department of Internal Medicine, Bronx Care Health System, Bronx, NY, USA
| | - Paul Kelly
- Department of Internal Medicine, Division of Infectious Disease, Bronx Care Health System, Bronx, NY, USA
| | - Alfonso Ortiz
- Department of Internal Medicine, Bronx Care Health System, Bronx, NY, USA
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Kubo K, Kimura N, Matsuda S, Tsuda M, Kato M. Cytomegalovirus Colitis with a Cobblestone Appearance. Case Rep Gastroenterol 2020; 14:279-285. [PMID: 32518539 PMCID: PMC7265724 DOI: 10.1159/000507649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/31/2020] [Indexed: 11/19/2022] Open
Abstract
Cytomegalovirus (CMV) colitis with a cobblestone appearance is rare, and its endoscopic and pathological features remain poorly described. A 78-year-old woman was admitted to our hospital for disturbance of consciousness, high-grade fever, and diarrhea occurring up to 7 times a day. Sigmoidoscopy revealed a circumferential ulcer with mucosal defect, an ulcer with a cobblestone appearance extending from the upper rectum to the sigmoid colon, and an irregular ulcer on the lower rectum. She was histopathologically diagnosed with CMV colitis and intravenously treated with ganciclovir (5 mg/kg) for 7 weeks. Colonoscopy after treatment revealed an improvement of the ulcers extending from the rectum to the sigmoid colon, but no significant improvement of her general condition. She died from sepsis 4 months after hospitalization. To our knowledge, this report represents a valuable addition to the CMV literature describing a rare case of CMV colitis with a cobblestone appearance.
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Affiliation(s)
- Kimitoshi Kubo
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, Japan
| | - Noriko Kimura
- Department of Pathology, National Hospital Organization Hakodate National Hospital, Hakodate, Japan
| | - Soichiro Matsuda
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, Japan
| | - Momoko Tsuda
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, Japan
| | - Mototsugu Kato
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hakodate, Japan
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Kim T, Lee HJ, Kim SM, Jung JH, Shin S, Kim YH, Sung H, Chong YP, Lee SO, Choi SH, Kim YS, Woo JH, Kim SH, Han DJ. Diagnostic usefulness of the cytomegalovirus (CMV)-specific T cell-based assay for predicting CMV infection after kidney transplant. Korean J Intern Med 2020; 35:438-448. [PMID: 29865778 PMCID: PMC7061014 DOI: 10.3904/kjim.2017.318] [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] [Received: 09/18/2017] [Accepted: 01/29/2018] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND/AIMS We evaluated the usefulness in kidney transplant (KT) candidates of cytomegalovirus (CMV)-specific enzyme-linked immunospot (ELISPOT) assays for predicting the development of post-transplant CMV infections. METHODS All adult recipients admitted for living-donor KT between March 2014 and March 2015 were prospectively enrolled except donor CMV-seropositive and recipient seronegative (D+/R-) recipients. All the enrolled patients underwent CMV-specific ELISPOT assays before transplant, and a researcher blinded to the results of these assays examined the patients for CMV infection at least 6 months post-transplant. RESULTS Of 133 KT recipients, 44 (33%) developed CMV infections. When we used the cut-off determined by receiver operator characteristic curve, 16 of the 34 patients (47%) with negative pp65-specific ELISPOT results (< 11 spots/200,000 cells) developed CMV infections, whereas 28 of the 99 patients (39%) with positive pp65-specific ELISPOT results at baseline (≥ 11 spots/200,000 cells) developed CMV infections after KT (p = 0.02). Based on the multivariable Cox regression model, negative pp65-specific ELISPOT assay results was an independent risk factor for CMV infection (adjusted hazard ratio [AHR], 1.87; 95% confidence interval [CI], 1.01 to 3.46; p = 0.047) as well as age (AHR, 1.05; 95% CI, 1.01 to 1.08; p = 0.007). CONCLUSION Pre-transplant CMV-specific ELISPOT assay appears to predict the development of CMV infections after KT in recipients at moderate risk such as CMV-seropositive recipients (Clinical Trial Registration Number NCT02025335).
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Affiliation(s)
- Taeeun Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Division of Infectious Diseases, Department of Internal Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Hyun-Jeong Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun-Mi Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Hee Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Sung-Han Kim, M.D. Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3305 Fax: +82-2-3010-6970 E-mail:
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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García-Tercero E, Alonso-Seco M, Pedro-Monfort C, Fernández-Sotos P, Cobos-Antoranz B, Rosado-Artalejo C, Martín-Correa E. [Cytomegalovirus colitis in an immunocompetent elderly patient]. Rev Esp Geriatr Gerontol 2020; 55:114-115. [PMID: 31326102 DOI: 10.1016/j.regg.2019.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/22/2019] [Accepted: 04/24/2019] [Indexed: 06/10/2023]
Abstract
Gastrointestinal tract involvement due to cytomegalovirus infection is a condition that usually occurs in immunocompromised patients, but is uncommon in immunocompetent patients. In a review of 33 cases, the median age was 68 years, and the accompanying symptoms were diarrhoea (76%), abdominal pain (52%), and haematochezia, or melena (27%). The case is presented of ctyomegalovirus colitis in an 85 year-old man with no previously identified immunocompromised states.
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Cho JH, Choi JH. Cytomegalovirus ileo-pancolitis presenting as toxic megacolon in an immunocompetent patient: A case report. World J Clin Cases 2020; 8:552-559. [PMID: 32110666 PMCID: PMC7031826 DOI: 10.12998/wjcc.v8.i3.552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/13/2019] [Accepted: 10/29/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) enterocolitis presenting in the form of pancolitis or involving the small and large intestines in an immunocompetent patient is rarely encountered, and CMV enterocolitis presenting with a serious complication, such as toxic megacolon, in an immunocompetent adult has only been reported on a few occasions.
CASE SUMMARY We describe the case of a 70-year-old male with no history of inflammatory bowel disease or immunodeficiency who presented with toxic megacolon and subsequently developed massive hemorrhage as a complication of CMV ileo-pancolitis. The patient was referred to our institute for abdominal pain and distension. Abdominal X-ray showed marked dilatation of ileum and whole colon without air-fluid level, and sigmoidoscopy with biopsy failed to reveal any specific finding. After 7 d of conservative treatment, massive hematochezia developed, and he was diagnosed to have CMV enterocolitis by colonoscopy with biopsy. Although the diagnosis of CMV enterocolitis was delayed, the patient was treated successfully by repeat colonoscopic decompression and antiviral therapy with intravenous ganciclovir.
CONCLUSION This report cautions that CMV-induced colitis should be considered as a possible differential diagnosis in a patient with intractable symptoms of enterocolitis or megacolon of unknown cause, even when the patient is non-immunocompromised.
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Affiliation(s)
- Joon Hyun Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Joon Hyuk Choi
- Department of Pathology, Yeungnam University College of Medicine, Daegu 42415, South Korea
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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. [PMID: 32000707 PMCID: PMC6990526 DOI: 10.1186/s12876-020-1174-y] [Citation(s) in RCA: 13] [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: 09/17/2019] [Accepted: 01/19/2020] [Indexed: 12/20/2022] Open
Abstract
Background Gastrointestinal (GI) cytomegaloviral (CMV) infection is common among patients with immunocompromised status; however, data specific to GI-CMV infection in immunocompetent patients are comparatively limited. Methods This retrospective study included patients diagnosed with GI-CMV infection at Siriraj Hospital (Bangkok, Thailand) during 2008–2017. Baseline characteristics, presentations, comorbid conditions, endoscopic findings, treatments, and outcomes were compared between immunocompetent and immunocompromised. Results One hundred and seventy-three patients (56 immunocompetent, 117 immunocompromised) were included. Immunocompetent patients were significantly older than immunocompromised patients (73 vs. 48.6 years, p < 0.0001). Significantly more immunocompetent patients were in the ICU at the time of diagnosis (21.0% vs. 8.6%, p = 0.024). GI bleeding was the leading presentation in immunocompetent, while diarrhea and abdominal pain were more common in immunocompromised. Blood CMV viral load was negative in significantly more immunocompetent than immunocompromised (40.7% vs. 12.9%, p = 0.002). Ganciclovir was the main treatment in both groups. Significantly more immunocompetent than immunocompromised did not receive any specific therapy (25.5% vs. 4.4%, p ≤ 0.01). Six-month mortality was significantly higher among immunocompetent patients (39.0% vs. 22.0%, p = 0.047). Independent predictors of death were old age and inpatient or ICU clinical setting. Treatment with antiviral agents was the only independent protective factor. Conclusion GI-CMV infection was frequently observed among immunocompetent elderly patients with comorbidities or severe concomitant illnesses. GI bleeding was the most common presentation. Blood CMV viral load was not diagnostically helpful. Significantly higher mortality was observed in immunocompetent than in immunocompromised patients, but this could be due to more severe concomitant illnesses in the immunocompetent group.
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Affiliation(s)
- Thanaboon Chaemsupaphan
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Julajak Limsrivilai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Chenchira Thongdee
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Asawin Sudcharoen
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ananya Pongpaibul
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nonthalee Pausawasdi
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Lee YC, Chiou CC, Wang JT, Yang YC, Tung SH, Hsieh SM. Non-traumatic perforation of the jejunum in a human immunodeficiency virus-infected patient receiving combination antiretroviral therapy: A case report. Medicine (Baltimore) 2019; 98:e18163. [PMID: 31804330 PMCID: PMC6919416 DOI: 10.1097/md.0000000000018163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Non-traumatic bowel perforation caused by cytomegalovirus (CMV) and Mycobacterium avium complex (MAC) infections has become rare among patients with acquired immunodeficiency syndrome (AIDS) in the era of combination antiretroviral therapy (cART); however, CMV-associated and MAC-related immune reconstitution inflammatory syndrome (IRIS) has subsequently emerged owing to the wide use of integrase inhibitor-based regimens. Here we report a case of spontaneous perforation of the jejunum in a patient with human immunodeficiency virus (HIV) infection with good compliance to cART. PATIENT CONCERNS A 32-year-old HIV-infected man developed CMV disease and DMAC infection, as unmasking IRIS, 3 days after the initiation of cART. After appropriate treatment for opportunistic infections, intermittent fever with enlarged lymph nodes in the abdomen occurred as paradoxical IRIS. The patient was administered prednisolone with subsequent tapering according to his clinical condition. DIAGNOSES Unexpected perforation of hollow organ during the titration of steroid dose with clinical presentations of severe abdominal pain was diagnosed by chest radiography. INTERVENTIONS He underwent surgical repair with peritoneal toileting smoothly. OUTCOMES He was discharged well with a clean surgical wound on post-operative day 10. LESSONS Bowel perforation may be a life-threatening manifestation of IRIS in the era of cART. Steroids should be avoided, if possible, to decrease the risk of bowel perforation, especially in IRIS occurred after opportunistic diseases involving the gastrointestinal tract.
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Affiliation(s)
- Yi-Chien Lee
- Department of Internal Medicine, Fu Jen Catholic University Hospital
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City
| | - Chien-Chun Chiou
- Department of Dermatology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Institute for Infectious Diseases and Vaccinology, National Health Research Institutes
| | - Yi-Chun Yang
- Department of Nursing, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Shao-Hsien Tung
- Department of Internal Medicine, Fu Jen Catholic University Hospital
| | - Szu-Min Hsieh
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
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Maeda T, Sakai H, Ozawa N, Sugiyama T, Takada J, Kubota M, Ibuka T, Shirakami Y, Araki H, Shimizu M. Acute cytomegalovirus infection in an immunocompetent patient with ulcerative colitis: A case report. Exp Ther Med 2019; 18:2271-2277. [PMID: 31452714 DOI: 10.3892/etm.2019.7823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/18/2019] [Indexed: 11/06/2022] Open
Abstract
Cytomegalovirus (CMV) is a ubiquitous member of the Herpesviridae family that can present with a variety of clinical manifestations, including encephalitis, retinitis, interstitial pneumonia and colitis. These serious symptoms are generally observed as opportunistic infections in immunocompromised hosts, including patients with acquired immunodeficiency syndrome and those receiving steroids and/or immunosuppressants. Symptomatic CMV infections in patients with ulcerative colitis are found in patients treated with steroids and/or immunosuppressants but rarely affect those who are not taking these agents. The present study reported the case of a young patient without concurrent use of immunosuppressive agents for the treatment of ulcerative colitis. The patient presented with acute mononucleosis and colitis caused by primary CMV infection. This was characterized by the presence of atypical lymphocytes and hepatosplenomegaly, elevation of transaminase levels, serology-positive anti-CMV IgM, and CMV antigenemia. Additionally, CMV-positive cells were histologically detected in colonic biopsy specimens. The patient's symptoms and clinical parameters improved following initiation of intravenous ganciclovir. It was concluded that even if patients with ulcerative colitis are not treated with steroids and/or immunosuppressants, significant attention should be paid to acute CMV infections in the context of severe or persistent colonic inflammation.
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Affiliation(s)
- Toshihide Maeda
- Department of Gastroenterology, Gifu University Hospital, Gifu 501-1194, Japan
| | - Hiroyasu Sakai
- Department of Gastroenterology, Gifu University Hospital, Gifu 501-1194, Japan
| | - Noritaka Ozawa
- Department of Gastroenterology, Gifu University Hospital, Gifu 501-1194, Japan
| | - Tomohiko Sugiyama
- Department of Gastroenterology, Gifu University Hospital, Gifu 501-1194, Japan
| | - Jun Takada
- Department of Gastroenterology, Gifu University Hospital, Gifu 501-1194, Japan
| | - Masaya Kubota
- Department of Gastroenterology, Gifu University Hospital, Gifu 501-1194, Japan
| | - Takashi Ibuka
- Department of Gastroenterology, Gifu University Hospital, Gifu 501-1194, Japan
| | - Yohei Shirakami
- Department of Gastroenterology, Gifu University Hospital, Gifu 501-1194, Japan
| | - Hiroshi Araki
- Department of Gastroenterology, Gifu University Hospital, Gifu 501-1194, Japan
| | - Masahito Shimizu
- Department of Gastroenterology, Gifu University Hospital, Gifu 501-1194, Japan
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CMV Ileitis: To Treat or Not to Treat? Implications of Initiating Biologic Therapy for Concurrent Crohn's Disease. Case Rep Gastrointest Med 2019; 2019:4513795. [PMID: 31321105 PMCID: PMC6609337 DOI: 10.1155/2019/4513795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 05/28/2019] [Indexed: 11/17/2022] Open
Abstract
Cytomegalovirus (CMV) enteritis is traditionally thought to be a self-limited infection in immunocompetent individuals. Consequently, current guidelines recommend against treating nonimmunocompromised patients with antiviral therapy. Conversely, recent data suggests that spontaneous resolution occurs less frequently than previously believed; furthermore, mortality rate in immunocompetent individuals is similar to that of the immunosuppressed. We present a case of a 43-year-old male who was simultaneously diagnosed with CMV ileitis and Crohn's Disease. When discovered concomitantly, there is no guidance in the current medical literature regarding the benefit of antiviral treatment of the CMV infection prior to initiating biologic therapy versus the risks of withholding treatment, as is currently recommended for nonimmunosuppressed individuals.
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Kolli S, Weissman S, Malik F, Chan O, Ona MA. Proctitis and Abdominal Aortic Aneurysm: Six Degrees of Separation. Cureus 2019; 11:e5129. [PMID: 31523560 PMCID: PMC6741391 DOI: 10.7759/cureus.5129] [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] [Received: 06/28/2019] [Accepted: 07/12/2019] [Indexed: 11/05/2022] Open
Abstract
Cytomegalovirus (CMV) is an aggressive virus responsible for a considerable amount of case fatalities. In the overwhelming majority of cases, this affects only the immunocompromised. Herein, we present a 76-year-old immunocompetent female who presented with gastrointestinal bleeding found to have rectal ulceration secondary to CMV infection. This manuscript aims to raise awareness of a rare cause of rectal bleeding. Hopefully, as such, our case will also prevent long-standing inflammation from persisting in patients with CMV and prevent it from contributing to cardiovascular pathology as seen in our patient.
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Affiliation(s)
- Sindhura Kolli
- Clinical Obesity Medicine, NYU Langone Health, New York, USA
| | - Simcha Weissman
- Internal Medicine, Hackensack University Medical Center, North Bergen, USA
| | - Fahad Malik
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
| | - Owen Chan
- Pathology, Pali Momi Medical Center, Affiliate of Hawai'i Pacific Health, Honolulu, USA
| | - Mel A Ona
- Gastroenterology, Pali Momi Medical Center, Affiliate of Hawai'i Pacific Health, Honolulu, USA
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Tao J, Lin XY, Tsia Hin Fong CJ, Wen ZF, Chen JN, Liang Q, Lin Q, Wu B. Cytomegalovirus infection in a T-cell lymphoma patient presenting with multiple gastrointestinal ulcers: a case report. Endosc Int Open 2019; 7:E615-E620. [PMID: 30993166 PMCID: PMC6461553 DOI: 10.1055/a-0869-7828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/11/2019] [Indexed: 11/29/2022] Open
Abstract
Background and study aims Gastrointestinal ulcers are responsible for a wide spectrum of diseases. Infection, drug-induced enteritis, malignancy, vasculitis and Inflammatory bowel disease are the most common causes; their clinical expression often varies according to the site and severity of intestinal involvement. We report on a 68-year-old male presenting with dyspepsia and melena and multiple gastrointestinal ulcers on endoscopy. We could not establish diagnosis of peripheral T-cell lymphoma not otherwise specified (PTCL-NOS) despite multiple biopsies taken on several endoscopic sessions, and cytomegalovirus (CMV) infection was documented by presence of inclusion bodies on pathology. The immunohistochemical study showed a mixture of B lymphocytes and predominantly T lymphocytes, negative for cluster of differentiation (CD)7. Southern blot gene rearrangement was positive for T-cell receptor beta. Our patient eventually expired from a massive gastrointestinal hemorrhage following four cycles of chemotherapy. We wish to emphasize that a CMV infection, as a comorbidity, can potentially mask and delay diagnosis of PTCL-NOS, especially in cases with aberrant immunophenotype presentation.
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Affiliation(s)
- Jin Tao
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China,Corresponding author Jin Tao, MD, PhD Associate-ProfessorDepartment of GastroenterologyThe Third Affiliated Hospital of Sun Yat-Sen UniversityNo. 600 Tianhe RoadGuangzhou 510630Guangdong ProvinceChina+86-20-85253336
| | - Xian Yi Lin
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | | | - Zhuo Fu Wen
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jian Ning Chen
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Qiong Liang
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Qu Lin
- Department of Oncology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Bin Wu
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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40
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A Practical Review of Cytomegalovirus in Gastroenterology and Hepatology. Gastroenterol Res Pract 2019; 2019:6156581. [PMID: 30984257 PMCID: PMC6431500 DOI: 10.1155/2019/6156581] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/05/2019] [Indexed: 02/06/2023] Open
Abstract
Human cytomegalovirus (CMV) is a ubiquitous Herpesviridae virus with a wide spectrum of pathology in humans. Host immunity is a major determinant of the clinical manifestation of CMV and can vary widely in the gastroenterology and hepatology practice setting. Immunocompetent patients generally develop a benign, self-limited mononucleosis-like syndrome whereas gastrointestinal tissue-invasive disease is more frequently seen in immunocompromised and inflammatory bowel disease patients. Additionally, liver allograft dysfunction is a significant consequence of CMV infection in liver transplant patients. While polymerase chain reaction and immunohistochemistry techniques allow for the reliable and accurate detection of CMV in the human host, the diagnostic value of different serologic, endoscopic, and histologic tests depends on a variety of factors. Similarly, latent CMV, CMV infection, and CMV disease carry different significance depending on the patient population, and the decision to initiate antiviral therapy can be complex and patient-specific. This review will focus on the pathophysiology, diagnosis, and management of CMV in patient populations relevant to the practice of gastroenterology and hepatology-liver transplant recipients, inflammatory bowel disease patients, and otherwise immunocompetent patients.
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41
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Abstract
PURPOSE OF REVIEW Cytomegalovirus (CMV) colitis is a relatively common end-organ infectious complication in immunocompromised hosts which negatively affects clinical outcomes. This paper presents the contemporary approaches to the diagnosis and management of CMV colitis and discusses some of the controversies of this condition, focusing on methods of diagnosis. RECENT FINDINGS While certain risk factors for CMV colitis are well recognized, the clinical as well as endoscopic features of this condition are nonspecific. Rapid diagnosis and management are usually needed, especially in critically ill patients, which necessitate invasive diagnostic procedures. Hematoxylin and eosin staining of colonic mucosal tissue may show the typical viral inclusions associated with CMV colitis that are highly specific for this condition. However, the staining has low sensitivity compared to immunohistochemistry, which is considered the gold standard for diagnosis of CMV colitis. Tissue polymerase chain reaction (PCR) is highly sensitive for diagnosis, but is controversial for many reasons, detailed in this paper. A high index of suspicion is needed, and once diagnosis is made, treatment should be highly considered to improve the outcome of these severely ill patients. Noninvasive diagnostic tests will be available in the future and will hopefully improve the diagnosis and care of patients with CMV colitis.
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Affiliation(s)
- Anat Yerushalmy-Feler
- Pediatric Gastroenterology Unit, Pediatrics Department, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, 6423906, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Shlomi Cohen
- Pediatric Gastroenterology Unit, Pediatrics Department, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, 6423906, Tel Aviv, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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42
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Case R, Stoner P, Myrick S, Zimmermann E. Solitary ascending colon ulcer diagnosed as gastrointestinal CMV disease. BMJ Case Rep 2019; 12:12/2/bcr-2018-226355. [PMID: 30739086 DOI: 10.1136/bcr-2018-226355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 42-year-old woman with a history of cholangiocarcinoma on adjuvant chemotherapy with capecitabine presented with painless haematochezia. She was found to have an isolated twenty-five mm ulcer in the ascending colon. Biopsies of the ulceration demonstrated typical cytomegalovirus (CMV) inclusions and her peripheral blood CMV PCR was significantly elevated. This is an unusual case of a solitary proximal colon ulcer. Non-steroidal anti-inflammatory drugs, inflammatory bowel disease and malignancy, are the most frequent causes of isolated ulcers in the proximal colon. Gastrointestinal (GI) CMV disease most commonly causes CMV colitis and is considered rare outside of the transplant population and other severely immunosuppressed patient groups. Patients who have received chemotherapy may also be at risk for GI CMV disease. The diagnosis should be suspected in patients who present with haematochezia or watery diarrhoea within a broad window of time after receiving chemotherapy.
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Affiliation(s)
- Robert Case
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Patrick Stoner
- Department of Internal Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Samuel Myrick
- Florida Cancer Affiliates Ocala, Ocala, Florida, USA
| | - Ellen Zimmermann
- Gastroenterology, University of Florida College of Medicine, Gainesville, Florida, USA
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43
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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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44
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Le PH, Kuo CJ, Wu RC, Hsu JT, Su MY, Lin CJ, Chiu CT. Pancolitis associated with higher mortality risk of cytomegalovirus colitis in patients without inflammatory bowel disease. Ther Clin Risk Manag 2018; 14:1445-1451. [PMID: 30154661 PMCID: PMC6108329 DOI: 10.2147/tcrm.s172071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Cytomegalovirus (CMV) colitis typically presents in immunocompromised and inflammatory bowel disease (IBD) patients. Several studies have been conducted on the endoscopic characteristics of CMV colitis in IBD patients. Objectives The endoscopic findings of CMV colitis in non-IBD patients and their relationship with inhospital mortality are unclear. We aimed to describe the endoscopic presentation in these patients and to determine the endoscopic predictors of inhospital mortality. Patients and methods Patients with CMV colitis diagnosed using histology between April 2002 and December 2016 at the Linkou Chang Gung Memorial Hospital, Taiwan, were retrospectively enrolled. Patients diagnosed with IBD during follow-up were excluded. Patient data, including underlying diseases, endoscopic presentation, laboratory data, clinical course, complications, and clinical outcomes, were collected. The independent risk factors for inhospital mortality were analyzed with logistic regression. The difference of overall survival was compared using Kaplan-Meier survival curve and log rank test. All statistical calculations were performed using SPSS software, version 21. Results Sixty-nine patients were enrolled, and 8 IBD patients were excluded. Within the 61 non-IBD patients, 31 were diagnosed by colonoscopy and others by sigmoidoscopy. Ulceration (77%) was the most common endoscopic finding, followed by a cobblestone appearance (19.7%), colitis with/without erosions (9.8%), pseudomembrane (9.8%), and tumor/polyp-like lesions (8.2%). Among the patients who underwent full-length colonoscopy, 35.3% presented with right-sided colitis, 23.5% with left-sided colitis, and 32.4% with pancolitis. Pancolitis was identified as a negative predictor of inhospital mortality (odds ratio, 6.8; 95% confidence interval, 1.233-37.497; p=0.028) and overall survival (log rank p=0.018). Conclusion Colonoscopy is recommended for precise CMV colitis diagnosis and outcome prediction in non-IBD patients.
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Affiliation(s)
- Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, .,Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan,
| | - Chia-Jung Kuo
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, .,Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan, .,College of Medicine, Chang Gung University, Taoyuan, Taiwan,
| | - Ren-Chin Wu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, .,Department of Pathology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jun-Te Hsu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, .,Department of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Yao Su
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, .,Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan, .,College of Medicine, Chang Gung University, Taoyuan, Taiwan,
| | - Chun-Jung Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, .,College of Medicine, Chang Gung University, Taoyuan, Taiwan,
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, .,Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan, .,College of Medicine, Chang Gung University, Taoyuan, Taiwan,
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45
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Park JH, Moon HS. Cytomegalovirus colitis in immunocompetent patients. Intest Res 2018; 16:504-505. [PMID: 30090053 PMCID: PMC6077313 DOI: 10.5217/ir.2018.16.3.504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 01/15/2018] [Accepted: 01/15/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Jae Ho Park
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hee Seok Moon
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
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46
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Koklu H, Imamoglu E, Tseveldorj N, Sokmensuer C, Purnak T, Kav T. Ulcerated colonic mass mimicking malignancy in an elderly patient. Geriatr Gerontol Int 2018; 18:651-653. [PMID: 29631339 DOI: 10.1111/ggi.13256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/22/2017] [Accepted: 12/10/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Hayretdin Koklu
- Department of Internal Medicine, Division of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Eylem Imamoglu
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Nomingerel Tseveldorj
- Department of Internal Medicine, Division of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Cenk Sokmensuer
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Tugrul Purnak
- Department of Internal Medicine, Division of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Taylan Kav
- Department of Internal Medicine, Division of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
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47
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Kang EA, Yoon H, Seo AY, Shin CM, Im JP, Park YS, Kim JS, Kim N, Lee DH. Characteristics of cytomegalovirus enterocolitis in patients with or without inflammatory bowel diseases. Scand J Gastroenterol 2018. [PMID: 29543102 DOI: 10.1080/00365521.2018.1450441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Cytomegalovirus (CMV) disease is more common in immunocompromised patients but may occur in people with normal immune function. In addition, CMV enterocolitis can aggravate inflammatory bowel diseases (IBD), but there was little knowledge of differences in clinical and endoscopic features of CMV enterocolitis between patients with IBD and without IBD. The aim of this study was to determine the difference in clinical implication in CMV enterocolitis between the IBD patients and non-IBD patients. METHODS This was a retrospective study of 82 patients with CMV enterocolitis based on the pathologic findings at two tertiary referral hospitals from 2003 to 2013. Clinical and endoscopic characteristics and clinical course were analyzed according to the presence of IBD. RESULTS Of the 82 patients, 25 (30.5%) had IBD and 57 (69.5%) did not have IBD. Hematochezia was more common in IBD patients (84.0% vs. 35.1%; p = .001), but fever and positive CMV antigenemia were more common in non-IBD patients (50.9% vs. 12.0%; p = .001; 54.4% vs. 28.0; p = .027). Endoscopic findings showed more ulcer with inflammation in IBD patients (68.0% vs. 35.2%; p = .005). Sixty-four patients were treated with antiviral agents and 12 patients who did not receive antiviral agents recovered spontaneously. All naturally healed patients were in normal immune status. CONCLUSIONS Hematochezia is more common in IBD patients and fever/CMV antigenemia is more common in patients without IBD. In patients without IBD, the natural resolution of CMV enterocolitis is expected at least in normal immune function.
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Affiliation(s)
- Eun Ae Kang
- a Department of Internal Medicine and Liver Research Institute , Seoul National University College of Medicine , Seoul , South Korea
| | - Hyuk Yoon
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Bundang-gu, Seongnam-si , Gyeonggi-do , South Korea
| | - A Young Seo
- c Health Promotion Center , Samsung Changwon Hospital, Sungkyunkwan University School of Medicine , Changwon-si , South Korea
| | - Cheol Min Shin
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Bundang-gu, Seongnam-si , Gyeonggi-do , South Korea
| | - Jong Pil Im
- a Department of Internal Medicine and Liver Research Institute , Seoul National University College of Medicine , Seoul , South Korea
| | - Young Soo Park
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Bundang-gu, Seongnam-si , Gyeonggi-do , South Korea
| | - Joo Sung Kim
- a Department of Internal Medicine and Liver Research Institute , Seoul National University College of Medicine , Seoul , South Korea
| | - Nayoung Kim
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Bundang-gu, Seongnam-si , Gyeonggi-do , South Korea
| | - Dong Ho Lee
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Bundang-gu, Seongnam-si , Gyeonggi-do , South Korea
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48
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Abstract
Cytomegalovirus (CMV) typically causes gastrointestinal infections in immunocompetent patients. Colonic perforations secondary to CMV are exceeding rare. We describe a 88-year-old male presenting with a week-long history of intractable abdominal discomfort, bloating, nausea and diarrhea. Flexible sigmoidoscopy revealed significant ulceration with yellowish slough. Emergency surgery was performed subsequently in view of multiple perforations in the rectosigmoid junction. CMV gastrointestinal infections demonstrated an ischemic process secondary to vasculitis, which accelerated the pathway to colonic perforation. CMV gastrointestinal infection should be considered as a differential diagnosis in patients with colonoscopy findings similar to ischemic colitis and Clostridium difficile infections.
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49
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Cytomegalovirus infection and steroid-refractory inflammatory bowel disease: possible relationship from an updated meta-analysis. Ir J Med Sci 2018; 187:935-942. [DOI: 10.1007/s11845-018-1752-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 01/17/2018] [Indexed: 12/19/2022]
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50
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Le PH, Lin WR, Kuo CJ, Wu RC, Hsu JT, Su MY, Lin CJ, Chiu CT. Clinical characteristics of cytomegalovirus colitis: a 15-year experience from a tertiary reference center. Ther Clin Risk Manag 2017; 13:1585-1593. [PMID: 29290686 PMCID: PMC5735984 DOI: 10.2147/tcrm.s151180] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Cytomegalovirus (CMV) colitis is considered rare in immunocompetent patients. Objective The predictors of mortality and the differences between immunocompetent and immunocompromised patients with this disease remain unknown. Thus, the aim of this retrospective cohort study was to clarify these issues. Patients and methods We enrolled all patients who were histologically diagnosed with CMV colitis between April 2002 and December 2016 in the Linkou Chang Gung Memorial Hospital. Patients were divided into two groups: immunocompetent and immunocompromised, and the differences between them were analyzed to develop in-hospital mortality predictors. Results A total of 69 patients (42, immunocompetent; 27, immunocompromised) were enrolled. The most common symptoms were melena in the immunocompetent group and diarrhea in the immunocompromised group. The in-hospital mortality rate showed no statistically significant difference between the two groups (26.2% vs 25.9%, P=0.981). Early diagnosis was the only significant independent predictor of in-hospital mortality (odds ratio [OR] 1.075, 95% CI 1.005-1.149, P=0.035). The cutoff of diagnostic timing was 9 days from admission, derived from the receiver operating characteristic curve using the Youden index. Conclusion CMV colitis in immunocompetent patients is markedly more common and fatal than has generally been acknowledged. Being alert to different ways in which this disease can present itself will enable early diagnosis and significantly reduce mortality.
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Affiliation(s)
- Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital.,Taiwan Association for the Study of Small Intestinal Diseases
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital.,College of Medicine, Chang Gung University
| | - Chia-Jung Kuo
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital.,Taiwan Association for the Study of Small Intestinal Diseases.,College of Medicine, Chang Gung University
| | - Ren-Chin Wu
- College of Medicine, Chang Gung University.,Department of Pathology
| | - Jun-Te Hsu
- College of Medicine, Chang Gung University.,Department of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Yao Su
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital.,Taiwan Association for the Study of Small Intestinal Diseases.,College of Medicine, Chang Gung University
| | - Chun-Jung Lin
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital.,Taiwan Association for the Study of Small Intestinal Diseases.,College of Medicine, Chang Gung University
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