Gastrointestinal hemorrhage secondary to cytomegalovirus after renal transplantation. A case report and review of the problem

HTLV-I carrier status disclosed at diagnosis of cytomegalovirus gastric ulcer

A 50-year-old man experienced epigastric pain and gastrofiberscopy (GF) disclosed A2 to H1 stage multiple ulcerative lesions in the stomach. Inclusion bodies were found in the gastric mucosal cells of the biopsy specimen and the cells were positive for monoclonal antibody against cytomegalovirus. Serum HTLV-I antibody was positive and no atypical lymphocytes were seen in the peripheral blood. Gancyclovir and lansoprazole were given. A follow-up GF showed good ulcer healing with immunohistological improvement. The patient died from acute hepatic failure of undetermined cause eleven months after diagnosis. This is the first case report where a cytomegaloviral-induced gastric ulcer disclosed HTLV-I carrier state.

Ileal perforation caused by cytomegalovirus infection in a critically ill adult

Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract is common and is most often seen in patients with acquired immunodeficiency syndrome (AIDS), inflammatory bowel disease, or those receiving immunosuppressive therapy. CMV infection of the small bowel accounts for only 4.3% of all CMV infections of the GI tract. Isolated cases of small bowel perforation due to CMV have been reported in AIDS patients, and all but one patient has died. This article reports the first case of an ileal perforation due to transfusion-associated CMV infection in a critically-injured non-AIDS patient. Immediate surgical resection and antiviral therapy led to complete recovery. The development of abdominal pain, fever, watery diarrhea, and GI bleeding in a critically ill patient should prompt the clinician to consider the diagnosis of CMV enteritis. If standard stool pathogens and Clostridium difficile toxin studies are nondiagnostic, endoscopic evaluation and CMV serology should be obtained. If CMV infection is confirmed, ganciclovir therapy should be initiated without delay. If bowel perforation occurs. prompt surgical resection is indicated. A heightened level of suspicion for CMV infection in multiply injured trauma victims and other critically ill patients, with earlier recognition of potential small bowel involvement, can hopefully decrease the incidence of bowel perforation, which is usually a fatal event.

The enhancer domain of the human cytomegalovirus major immediate-early promoter determines cell type-specific expression in transgenic mice

The human cytomegalovirus (HCMV) major immediate-early promoter (MIEP) is one of the first promoters to activate upon infection. To examine HCMV MIEP tissue-specific expression, transgenic mice were established containing the lacZ gene regulated by the MIEP (nucleotides -670 to +54). In the transgenic mice, lacZ expression was demonstrated in 19 of 29 tissues tested by histochemical and immunochemical analyses. These tissues included brain, eye, spinal cord, esophagus, stomach, pancreas, kidney, bladder, testis, ovary, spleen, salivary gland, thymus, bone marrow, skin, cartilage, and cardiac, striated and smooth muscles. Although expression was observed in multiple organs, promoter activity was restricted to specific cell types. The cell types which demonstrated HCMV MIEP expression included retinal cells of the eye, ductile cells of the salivary gland, exocrine cells of the pancreas, mucosal cells of the stomach and intestine, neuronal cells of the brain, muscle fibers, thecal cells of the corpus luteum, and Leydig and sperm cells of the testis. These observations indicate that the HCMV MIEP is not a pan-specific promoter and that the majority of expressing tissues correlate with tissues naturally infected by the virus in the human host.

Cytomegalovirus colitis in AIDS: plain abdominal radiograph findings

The findings on the plain abdominal radiographs of 15 patients with cytomegalovirus (CMV) colitis and AIDS were reviewed and compared to an age, sex, CD4 count and symptom-matched control group. The radiographs were examined for mucosal thickening, bowel dilatation, pneumatosis and perforation. Nodular mucosal lesions were the most significant abnormality in those with CMV colitis being present in seven compared to none in the control group (P = 0.006 two tailed). Differences between the CMV colitis group and the control group as regards the other features were not significant. The finding of pneumatosis is the first time this has been described in patients with CMV colitis and AIDS. No evidence of perforation was demonstrated and this is attributed to a high index of suspicion in those with characteristic signs and symptoms in addition to early sigmoidoscopy and prompt treatment.

Cytomegalovirus gastritis: protean radiologic features

Infection with cytomegalovirus (CMV) is a major feature of acquired immunodeficiency syndrome (AIDS). Gastrointestinal involvement is being seen more frequently. Our collective experience involves nine patients with stomach involvement. Seven patients were intravenous drug abusers or homosexuals with AIDS. One developed CMV gastritis as a complication of leukemia and one patient was a West African with lymphoma and human immunodeficiency virus (HIV) infection. All our patients had biopsy-proven CMV inclusion bodies. The radiographic appearances varied widely. The findings included markedly thickened edematous folds, erosive gastritis with aphthous ulceration, and superficial and deep ulceration. One patient had deep ulceration with fistula formation. Computed tomographic (CT) scans confirmed the greatly thickened gastric wall and coarsened folds in two patients. Associated gastrointestinal infections included candida and herpes, and, in addition, pneumocystis carinii pneumonia (PCP) was present in two patients. CMV gastritis may mimic several other conditions including erosive gastritis, peptic ulceration, lymphoma, and carcinoma. It should be strongly considered in immunosuppressed patients.

CMV enteritis causing hemorrhage and obstruction in an infant with AIDS

Serious gastrointestinal infections from cytomegalovirus (CMV) are often observed in immunosuppressed patients especially those with acquired immunodeficiency syndrome (AIDS). Hemorrhage and perforation have been frequent consequences. We present a case of CMV enteritis in an infant with AIDS who suffered massive hemorrhage and subsequent fatal small bowel obstruction from this condition. Gross findings at laparotomy were striking, diffuse, large yellowish plaques along the entire length of the small bowel. Each of these had a central ulceration. Each eventually caused a partial narrowing resulting in refractory small bowel obstruction. Biopsy of one of these lesions demonstrated many cells with typical cytomegalic inclusion bodies. This report illustrates a newly recognized type of CMV enteritis that can affect an infant and be readily recognized at laparotomy.

Cytomegalovirus infection with acute erosive esophagitis

A healthy young adult is described in whom acute erosive esophagitis developed four weeks after undergoing splenectomy and receiving six units of blood because of trauma. Cytomegalovirus inclusion bodies were identified in esophageal mucosa, and cytomegalovirus was cultured from blood and throat. Within three weeks, the patient's anticytomegalovirus antibody had increased four-fold. The patient was initially anergic and had a titer of antinuclear antibody of 1:10,240. His symptoms and histopathologic findings disappeared over five weeks, and his immunologic abnormalities were partially corrected. It is suggested that cytomegalovirus was the primary cause of gastrointestinal disease in this nonimmunocompromised patient.

Rash produced by mouse cytomegalovirus

A striking rash was produced in mice 4 days after intravenous injection of large doses of murine cytomegalovirus. Routine histology showed cell infiltration, vascular damage, and hemorrhage. Immunofluourescent staining showed dermal but not epidermal infection, and this appeared to be initiated after the localization in small blood vessels of circulating virus or of virus-containing leukocytes. The rash was accompanied by a high level of complement-requiring neutralizing antibodies in the serum and extensive deposition of immune complexes in the renal glomeruli containing immunoglobulin G, immunoglobulin M, and complement. When mice were depleted of complement by cobra venom factor, when antibody responses were reduced by cyclophosphamide treatment, or when a prostaglandin inhibitor (indomethacin) was given, the rash was much less severe. The role of direct viral damage and inflammatory and immune responses in the genesis of the lesions is discussed.

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

Cytomegalovirus infection in immunosuppressed patients is well known. It usually appears as an interstitial pneumonitis that may progress to a disseminated viral infection. The authors report on two patients who, after bone marrow transplantation, had signs and symptoms of gastric ulceration as the initial manifestation of cytomegalovirus infection. Both died with disseminated cytomegalovirus infection. Though gastric presentation is unusual for cytomegalovirus infection, epigastric pain and gastrointestinal hemorrhage in a bone marrow transplant patient may herald a potentially lethal viral infection.

Cytomegalic inclusion disease diagnosed endoscopically

Two patients who received renal transplants developed erosions or ulcers in the upper gastrointestinal tract. In both cases endoscopic evaluation enabled a diagnosis of cytomegalovirus (CMV) infection to be made quickly and safely. We emphasize the importance of early diagnosis of CMV infection and how endoscopy may be helpful.