Cytomegalovirus ileitis with protein-losing enteropathy in an immunocompetent adult

Cytomegalovirus Duodenitis Causing Persistent Hypoalbuminemia and Ascites After Liver Transplantation

A 44-year-old male had persistent hypoalbuminemia and ascites after liver transplantation. Imaging of the liver and gastrointestinal system was normal. Urine examination was negative for proteinuria. A diagnosis of protein-losing enteropathy was suspected, and a duodenal biopsy was done. Duodenal biopsy was positive for cytomegalovirus (CMV). The patient improved with CMV treatment.

Cytomegalovirus Diseases of the Gastrointestinal Tract in Immunocompetent Patients: A Narrative Review

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.

[Severe cytomegalovirus-associated protein losing gastropathy in an immunocompetent adult]

INTRODUCTION

Clinical expression of cytomegalovirus (CMV) infection is numerous and depends on the immune status of the host. In immunocompromised patients, CMV disease corresponds to reactivation of the virus with tissue damage responsible for significant morbidity and mortality. In immunocompetent adults, primary CMV infection is usually asymptomatic but may rarely result in severe organ damage.

OBSERVATION

We report the case of a 28-year-old man, considered immunocompetent and without medical history, presenting with a primary CMV infection revealed by a severe protein-losing gastroenteropathy (serum albumin level: 18.9g/L). The CT scan showed a gastro-duodeno-jejuno-ileitis pattern. Upper intestinal endoscopy revealed diffuse ulcerated and congestive gastritis predominantly in the fundus. Histological analysis of the biopsies showed no viral inclusion and no immunohistochemical staining reaction, but a high viral load (5.61 log). Treatment was symptomatic associated with anticoagulation due to the major hypoalbuminemia. The patient slowly recovered, and normal clinical examination and blood tests were observed two months after the onset of symptoms.

CONCLUSION

Severe CMV organ involvement in the immunocompetent patient is very rare but potentially serious. Digestive involvement complicated by exudative enteropathy is possible. Evolution is usually favorable without the need for antiviral treatment.

Severe cytomegalovirus encephalitis in an immunocompetent healthy young woman: A case report

Cytomegalovirus (CMV) causes a mild illness in immunocompetent patients. Conversely, it can be life-threatening in immunocompromised or critically ill patients. We present a 48-year-old immunocompetent woman presenting primary severe CMV encephalitis. She presented with a headache, fever, and drowsiness. She did not respond to empirical treatment. Her level of consciousness deteriorated, she was put on mechanical ventilation on day two. Bacterial culture, herpes simplex virus, and tuberculosis were negative in cerebrospinal fluid (CSF). After three weeks, the patient was transferred to our center due to financial matters. Brain magnetic resonance imaging (MRI) showed diffuse hydrocephalus, periventricular T2 hyperintensity, patchy basal ganglia, and diffuse leptomeningeal enhancement. CMV polymerase chain reaction (PCR) was positive in cerebrospinal fluid (CSF) specimen. Ganciclovir (5 mg/kg/IV q12h) was initiated. Subsequently, a brain shunt was inserted. Her level of consciousness raised, she was weaned from the ventilator. She was discharged after 52 days in a bedridden state, quadriplegic, and only able to speak words with a minor swallowing problem. She remained in the same condition for one year. She was expired one year later due to aspiration pneumonia after four weeks of hospitalization. Early diagnosis and treatment of severe CMV encephalitis are crucial to prevent neurological sequelae.