Human cytomegalovirus infection of the gastrointestinal tract in apparently immunocompetent patients

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.

The Unmasking of Cytomegalovirus as an Accomplice to Helicobacter pylori-Induced Severe Acute Gastroenteritis in a Healthy Host

Cytomegalovirus (CMV) belongs to the Herpesviridae family, and it is considered the largest virus to infect humans. Primary CMV infection frequently targets immunodeficient patients and is often symptomatic. However, it may remain latent or clinically unapparent for years in immunocompetent individuals. CMV infection rarely presents as an invasive disease in the latter group of individuals, in which case, the most common site of involvement in the gastrointestinal tract. When CMV affects the gastrointestinal tract, the colon and stomach are the 2 frequently involved sites. This case report describes a unique case of an immunocompetent patient who presented with acute excruciating periumbilical pain and was diagnosed with acute gastritis secondary to CMV infection and possible Helicobacter pylori-associated chronic active gastritis. Symptoms resolved entirely soon after treatment with antimicrobials that cover for both infections. The diagnosis was based on histopathologic findings from biopsies taken from the stomach during the endoscopic evaluation combined with positive CMV serology and positive CMV-deoxyribonucleic acid.

Emergency gastrointestinal tract operation associated with cytomegalovirus infection

Purpose

Cytomegalovirus (CMV) infection is common in immunocompromised patients. Enterocolitis caused by CMV infection can lead to perforation and bleeding of the gastrointestinal (GI) tract, which requires emergency operation. We investigated the demographics and outcomes of patients who underwent emergency operation for CMV infection of the GI tract.

Methods

This retrospective study was conducted between January 2010 and December 2020. Patients who underwent emergency GI operation and were diagnosed with CMV infection through a pathologic examination of the surgical specimen were included. The diagnosis was confirmed using immunohistochemical staining and evaluated by experienced pathologists.

Results

A total of 27 patients who underwent operation for CMV infection were included, 18 of whom were male with a median age of 63 years. Twenty-two patients were in an immunocompromised state. Colon (37.0%) and small bowel (37.0%) were the most infected organs. CMV antigenemia testing was performed in 19 patients; 13 of whom showed positive results. The time to diagnose CMV infection from operation and time to start ganciclovir treatment were median of 9 days. The reoperation rate was 22.2% and perforation was the most common cause of reoperation. In-hospital mortality rate was 25.9%.

Conclusion

CMV infection in the GI tract causes severe effects, such as hemorrhage or perforation, in immunocompromised patients. When these outcomes are observed in immunocompromised patients, suspicion of CMV infection and further evaluation for CMV detection in tissue specimens is required for proper treatment.

Cytomegalovirus proctitis in non-human immunodeficiency virus infected patients: A case report and literature review

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.

Cytomegalovirus-associated esophagitis on early esophageal cancer in immunocompetent host: a case report

Background

Cytomegalovirus (CMV)-associated gastrointestinal diseases usually occur in immunocompromised patients; however, few cases has also been described in healthy hosts despite still unclear pathological mechanisms. CMV esophagitis causes various lesions, such as erythematous mucosa, erosions, and ulcers, although such inflammatory changes can appear in superficial esophageal cancers or in surrounding areas. CMV-associated esophagitis has been also reported in cancer patients, but typically in those with advanced and/or terminal stage cancers secondary to chemoradiotherapy-induced immunosuppression or the physiologic demands of the malignancy itself. To our best knowledge, we firstly report on an immunocompetent patient subject to endoscopic submucosal dissection (ESD) for early esophageal cancer complicated with CMV infection.

Case presentation

A 77-year-old man underwent esophagogastroduodenoscopy (EGD) at a local clinic. EGD revealed a lugol-unstained reddish lesion with whitish exudates in the middle-distal esophagus. Histological evaluation of lesion biopsy revealed atypical squamous epithelium with CMV-positive granulation tissue and aggregates of macrophages, prompting referral for further examination and treatment. Magnifying endoscopy with narrow-band imaging showed an erosive lesion with white moss in a well-demarcated brownish area with irregular mesh-like microvessels. ESD was performed for diagnosis and treatment. Histopathological examination of the resected specimen revealed superficial, moderately differentiated squamous cell carcinoma (SCC) with multiple lymphatic infiltration, and few CMV-positive cells were found in the erosive part of the SCC. Interestingly, he had no underlying conditions to predispose to CMV infection and no risk factors for esophageal cancer, other than gender and age. He received neither steroids for stricture prevention nor antiviral agents post-EGD and 4-month follow-up was negative for esophagitis.

Conclusions

This is the first report of a case of CMV esophagitis superimposed on early esophageal cancer in an immunocompetent host and might provide valuable information for possible adverse effects of steroid administration during ESD procedures, despite their common use for prevention of post-ESD stricture.

Clinical Features, Endoscopic Findings, and Predictive Factors for Mortality in Tissue-Invasive Gastrointestinal Cytomegalovirus Disease between Immunocompetent and Immunocompromised Patients

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.

CMV Disease of Upper GI Tract in Immunocompetent Host: Two Case Reports and Brief Review of Literature

Gastrointestinal cytomegalovirus (GI-CMV) infection is well-reported in immunocompromised individuals and those on chemotherapy or other immunosuppressive medications. Rarely, CMV infection of gastrointestinal tract (GIT) occurs in immunocompetent individuals. Colon is the most common site of GI involvement with CMV. However, in immunocompetent individuals, upper GIT involvement is more common. Clinical spectrum of GI-CMV disease is variable and depends on the location and severity of the disease. Prompt diagnosis and treatment aids in reducing morbidity and mortality related to CMV involvement in GI tract. We present two interesting cases of CMV-induced GI ulcers in immunocompetent individuals with brief review of diagnostic and treatment challenges associated with CMV disease in immunocompetent individuals.

[Evaluation and management of infectious esophagitis in immunocompromised patients and immunocompetent individuals]

Among the many causes of the inflammatory process in the esophagus, infectious diseases are becoming increasingly important due to their steady growth. Previously esophageal infections have traditionally been associated with immunodeficiency syndromes, but now in clinical practice, these disorders are becoming increasingly recognized in immunocompetent individuals. Early diagnosis of infectious esophagitis is necessary to develop effective treatment tactics, and, as a result, reduce the risk of complications and adverse outcomes of the disease. This study reviewed the most clinical relevant pathogens of infectious esophagitis, both among patients with immunodeficiency and among healthy individuals. Specific diagnostic, risk factors, clinical presentation and therapeutic features were considered depending on the immune status of patients.

Cytomegalovirus Colitis Followed by Colonic Pseudolipomatosis and Gastric Emphysema in a Post-resuscitation Patient

A 64-year-old Japanese man suffered cardiopulmonary arrest, which may have resulted from sepsis and/or hyperosmolar hyperglycemic non-ketonic coma, and was admitted after successful resuscitation. He had watery diarrhea on day 18 and was diagnosed with cytomegalovirus enterocolitis. In addition, computed tomography performed on day 27 and colonoscopy revealed gastric emphysema and intestinal pseudolipomatosis, respectively. This report is the first to describe a patient with cytomegalovirus enterocolitis and subsequent gastric emphysema and pseudolipomatosis. Gastrointestinal cytomegalovirus infection may underlie gastric emphysema and intestinal pseudolipomatosis, particularly in patients with relative or obvious immune dysfunction.

Patient characteristics, clinical manifestations, prognosis, and factors associated with gastrointestinal cytomegalovirus infection in immunocompetent patients

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.

Severe Bleeding due to Cytomegalovirus Esophagitis in a Patient with Diabetes after Interbody Fusion Surgery

A 49-year-old man with diabetes taking clopidogrel and celecoxib underwent interbody fusion surgery for spinal spondylolysis. Ten days after the surgery, he vomited a large amount of fresh blood. A blood examination revealed hemodynamic failure. Esophagogastroduodenoscopy showed an adherent blood clot and multiple superficial ulcers in the esophagus. Endoscopic hemostasis was successfully achieved. Biopsy specimens from the esophageal ulcer showed positive immunohistochemical staining results for anti-CMV antibodies. The esophageal ulcer improved after the oral administration of ganciclovir. This case emphasizes that CMV esophagitis with bleeding can occur in a diabetic patient with a poor nutritional status due to relative immune dysfunction.

Esophagitis in patients without gastroesophageal reflux disease or eosinophilic esophagitis: diagnostic considerations

PURPOSE OF REVIEW

A multitude of inflammatory diseases other than gastroesophageal reflux disease (GERD) and eosinophilic esophagitis can affect the esophagus. Despite the deceptively simple organization of squamous mucosa and its limited number of inflammatory responses, a wide array of histologic patterns can be seen in inflammatory disorders involving the esophagus. Each such histologic pattern is associated with a limited number of underlying conditions, and the clinician can use this information to narrow the differential diagnosis. The purpose of this review is to review and discuss the pathologic diagnosis of esophagitis caused by conditions other than GERD or eosinophilic esophagitis, with an emphasis on recent developments in the field.

RECENT FINDINGS

Recent studies suggest that lymphocytic esophagitis may be a histologic manifestation of esophageal motility disorders. Immunophenotypic features of infiltrating lymphocytes may be helpful in this scenario. immunoglobulin G4-related disease has been implicated as a cause of esophageal inflammation with ulceration, strictures, and mass-forming fibrosis, whereas epidermoid metaplasia has been linked molecularly to the squamous cell neoplasia pathway.

SUMMARY

Improved knowledge and appreciation of the pathology of esophageal inflammation are needed to better understand the pathogenesis of various types of esophagitis, and to inform new approaches to the therapy and management of inflammatory esophageal diseases.

A Practical Review of Cytomegalovirus in Gastroenterology and Hepatology

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.

Pathologic Features of Infectious Gastritis

This manuscript presents a review of infectious causes of gastritis aimed at the practicing anatomic pathologist. We shall highlight unique histologic findings and clinical attributes that will assist those analyzing endoscopically obtained mucosal biopsies of the stomach or resection specimens.

Cytomegalovirus ulcerative oesophagitis in a young healthy immunocompetent patient

Cytomegalovirus (CMV) gastrointestinal disease usually arises in patients with immunodeficiency or immunosuppression, being rare in immunocompetent hosts. Although increasing in incidence, few cases of CMV gastrointestinal disease have been described among young healthy patients. Currently, there is uncertainty in approaching these patients, including the need for antiviral therapy that remains to be established. This case report describes a CMV ulcerative oesophagitis in a young healthy immunocompetent patient with good evolution with no need for antiviral therapy, the youngest case being reported in the literature until now.

Bilateral vocal cord immobility resulting from cytomegalovirus pharyngitis: A case report

Human cytomegalovirus (CMV) is an infectious herpes virus present in approximately 50% of the world's population. Pharyngitis is an uncommon manifestation of CMV infection, and vocal cord immobility (VCI) following CMV pharyngitis is quite rare. An 83-year-old man with well-controlled diabetes mellitus and hypertension was admitted due to dyspnea, odynophagia, and dysphagia. Laryngeal fiberscopy revealed bilateral vocal cords almost fixed at the median position, with mucosal redness, swelling, and edema at the hypopharyngeal area. The airway was so narrowed that an emergency tracheostomy was performed to secure an airway. VCI resulting from a malignant tumor was suspected at first, but repeated pathological examinations revealed CMV infection in the pharyngeal mucosa. Despite intravenous ganciclovir treatment (5 mg/kg), the patient's bilateral VCI improved only slightly. Laryngeal electromyography was used to investigate the causes of VCI, and revealed vocal fold paralysis on the left side and cricoarytenoid joint fixation on the right side. This case highlights the importance of considering CMV infection in the differential diagnosis of patients with pharyngitis and VCI. To the best of our knowledge, this is the first case report describing the etiology of VCI following CMV pharyngitis using laryngeal electromyography.

[Adrenalitis]

Inflammation of the adrenal glands is caused by autoimmunopathies or infections and can induce adrenal insufficiency. Autoimmune lymphocytic adrenalitis is often combined with other autoimmune diseases and the most frequent cause of Addison's disease; however, it only becomes clinically apparent when more than 90 % of the adrenal cortex has been destroyed. Histological features are characterized by lymphoplasmacytic inflammation leading to an increased destruction of adrenocortical tissue but less severe courses can also occur. The second most frequent form of adrenalitis is adrenal tuberculosis, showing typical granulomatous findings that are nearly always caused by spreading from a tuberculous pulmonary focus. Other bacterial as well as viral infections, such as Epstein-Barr virus (EBV), cytomegalovirus (CMV) and others, generally affect the adrenal glands only in patients with immunodeficiency disorders. In these infections, the adrenal cortex and medulla are frequently involved to roughly the same extent. Although surgical specimens from inflammatory adrenal lesions are extremely rare, the various forms of adrenalitis play an important role in the post-mortem examination of the adrenal glands for clarification of unclear causes of death (e.g. death during an Addisonian crisis).

The clinical characteristics and manifestations of cytomegalovirus esophagitis

Esophagitis is the second most common gastrointestinal manifestation of cytomegalovirus (CMV) infection after colitis. CMV esophagitis has been reported in patients who have undergone transplantation, are on long-term renal dialysis, or who have the human immunodeficiency virus infection. This study aimed to investigate the clinical characteristics and manifestations of CMV esophagitis in patients who underwent diagnostic endoscopy. A total of 16 patients with histologically proven CMV infection were identified from 1539 patients with esophageal ulcers and analyzed retrospectively (January 2006 to December 2013). Patients' personal data (age, smoking, and alcohol consumption), underlying systemic diseases (diabetes mellitus, end-stage renal disease, and chronic obstructive pulmonary disease), malignancy, indication for esophagogastroduodenoscopy, endoscopic characteristics, and diagnostic methods (pathological or serological findings) were collected for further analysis. Among the patients with CMV esophagitis, the mean age was 59.94 years (range, 23-84 years). The male : female ratio was 1.67:1. Odynophagia and epigastralgia were common symptoms. Of the 16 patients, 3 (18.75%) were infected with the human immunodeficiency virus and 9 (56.25%) had an underlying malignancy, including lung cancer (6 patients), esophageal cancer (2 patients), gastric cancer (1 patient), ampulla of Vater cancer (1 patient), and lymphoma (1 patient). Six of the 9 patients (66.7%) with malignancy had been administered concurrent chemoradiotherapy (CCRT). In this study, patients with malignancy who had been administered CCRT were at increased risk for CMV esophagitis, which had not been reported before in the literature. CMV esophagitis should be considered as a potential treatment-related complication of CCRT.

Gastritis as a manifestation of primary CMV infection in an immunocompetent host

The cytomegalovirus (CMV) disease spectrum is very wide, with symptomatic infections being rare in immunocompetent hosts. We present the case of a 31-year-old immunocompetent man diagnosed with CMV gastritis in the context of primary infection. The most important laboratory abnormalities leading to diagnosis were: elevation of liver enzymes (3-4× the upper limit of normal), thrombocytopenia (133 G/L), lymphocytosis (55%-4.2 G/L) with activated lymphocytes, CMV IgM positive (negative IgG), CMV viral load of 5700 copies/mL (real-time PCR); autoimmunity study showed antiparietal cell antibodies; abdominal ultrasonography detected homogenous splenomegaly (14.6×13.4 cm) and endoscopy unveiled superficial erosions of the gastric antrum that were biopsied. Anatomopathology and immunohistochemistry of the samples identified cytomegalic inclusions in endothelial cells. Cellular and humoral immunity deficits were excluded. As the patient developed severe asthaenia, adynamia and epigastric pain, he was administered gancyclovir 5 mg/kg intravenously twice daily for 7 days, with resolution of symptoms and gastric lesions confirmed by re-evaluation through endoscopy.

Symptomatic cytomegalovirus gastrointestinal infection with positive quantitative real-time PCR findings in apparently immunocompetent patients: a case series

Cytomegalovirus (CMV) gastrointestinal disease rarely occurs in immunocompetent patients, and is mainly diagnosed on the basis of histopathological findings. Real-time PCR for CMV DNA quantification is considered to be a useful diagnostic tool, but its place in the diagnostic strategy is not clearly defined. The goal of the study was to describe the clinical and paraclinical features of apparently immunocompetent patients with CMV gastrointestinal disease diagnosed according to quantitative PCR results. In this retrospective study conducted in a 1500-bed tertiary-care centre, we reviewed the case records of apparently immunocompetent patients with positive findings of CMV DNA in gastrointestinal biopsies with compatible symptoms and endoscopic findings. A total of 13 patients were included between January 2007 and December 2010. The median age was 81 years, and 54% of patients had underlying immune-modulating conditions. Diarrhoea, haematochezia and dysphagia were the main reported symptoms, and ulcers were the main endoscopic findings. The mean value of CMV DNA load in gastrointestinal biopsies was 3845 copies/μg total DNA (range, 15-15 500 copies/μg total DNA). The highest values were found in two patients who were diagnosed with adenocarcinoma in the subsequent course of CMV infection. Clinical features were similar to those in previous series in which diagnosis was based on histopathological analysis. Elderly people are more commonly affected, and a link with immune senescence is possible. Quantification of CMV DNA seems to be a useful tool for diagnosis when combined with clinical and endoscopic findings, but further studies are necessary to interpret quantitative values.

Non-reflux esophagitis: a review of inflammatory diseases of the esophagus exclusive of reflux esophagitis

Esophagitis is a frequent cause of clinical symptoms and is often an indication for upper endoscopy. Mucosal biopsies are procured for diagnostic purposes and may be used to assess the efficacy of treatment, as in patients with eosinophilic esophagitis. This article outlines salient clinical and pathologic features of diseases that cause esophagitis exclusive of reflux esophagitis.

Cytomegalovirus enterocolitis in apparently immunocompetent hosts: evaluation of the radiologic findings and clinical features

OBJECTIVE

To describe the clinical and radiologic features of cytomegalovirus (CMV) enterocolitis in apparently immunocompetent hosts.

MATERIALS AND METHODS

Our institutional review board approved this retrospective study, and informed consent was waived. Twelve apparently immunocompetent patients (7 women and 5 men; mean age, 58 years) with pathologically proven CMV enterocolitis were included. Computed tomographic (CT) scans were retrospectively reviewed to determine the extent and the location of mural thickening, maximal mural thickness, enhancement pattern, that is, single-halo, double-halo, and homogeneous patterns, and ascites.

RESULTS

Eight patients had comorbidities potentially affecting the host immune status, whereas 4 patients were apparently healthy before presentation. On CT, all patients showed mural thickening (range, 4-11 mm) involving the colon (n = 8), the small bowel (n = 1), or both (n = 3). Segmental involvement was most common (n = 9 for colon and n = 2 for small bowel), whereas focal involvement of the rectum (n = 1) and diffuse involvement of the entire ileum (n = 1) or the entire small bowel and colon (n = 1) were also noted. Colonic lesions showed variable enhancement patterns, including the single-halo (n = 6), homogeneous (n = 3), and double-halo patterns (n = 2), whereas all small-bowel lesions in 4 patients exhibited a single-ring pattern. Ascites was present in 7 patients. Complications requiring surgery occurred in 3 patients and included refractory bleeding (n = 2) and bowel perforation (n = 1).

CONCLUSIONS

Cytomegalovirus enterocolitis in immunocompetent hosts typically develops in elderly subjects with comorbidities, although it may also affect relatively young and healthy subjects. On CT, it is characterized by mild mural thickening of the small bowel and the colon and frequently shows segmental involvement and a single-halo enhancement pattern.

The cytomegalovirus-encoded chemokine receptor US28 promotes intestinal neoplasia in transgenic mice

US28 is a constitutively active chemokine receptor encoded by CMV (also referred to as human herpesvirus 5), a highly prevalent human virus that infects a broad spectrum of cells, including intestinal epithelial cells (IECs). To study the role of US28 in vivo, we created transgenic mice (VS28 mice) in which US28 expression was targeted to IECs. Expression of US28 was detected in all IECs of the small and large intestine, including in cells expressing leucine rich repeat containing GPCR5 (Lgr5), a marker gene of intestinal epithelial stem cells. US28 expression in IECs inhibited glycogen synthase 3β (GSK-3β) function, promoted accumulation of β-catenin protein, and increased expression of Wnt target genes involved in the control of the cell proliferation. VS28 mice showed a hyperplastic intestinal epithelium and, strikingly, developed adenomas and adenocarcinomas by 40 weeks of age. When exposed to an inflammation-driven tumor model (azoxymethane/dextran sodium sulfate), VS28 mice developed a significantly higher tumor burden than control littermates. Transgenic coexpression of the US28 ligand CCL2 (an inflammatory chemokine) increased IEC proliferation as well as tumor burden, suggesting that the oncogenic activity of US28 can be modulated by inflammatory factors. Together, these results indicate that expression of US28 promotes development of intestinal dysplasia and cancer in transgenic mice and suggest that CMV infection may facilitate development of intestinal neoplasia in humans.

The clinical spectrum of cytomegalovirus colitis in adults

BACKGROUND

Colonic cytomegalovirus reactivation rarely occurs in adults without inflammatory bowel disease or a known immunosuppressive state.

AIM

To describe our experience with such patients.

METHODS

All consecutive admissions of patients with possible cytomegalovirus colitis, between 1995 and 2006, were reviewed retrospectively.

RESULTS

Nineteen patients were studied. Most of the patients were elderly with multiple co-morbidities. Three main forms of disease presentation were recognized: acute diarrhoea, chronic diarrhoea and lower gastrointestinal bleeding. Colonic mucosal intranuclear inclusion bodies were found in 12 patients. Thirteen patients had cytomegalovirus viraemia (either by polymerase chain reaction and/or by white blood cell-cytomegalovirus antigenaemia test). Ganciclovir therapy was given to only eight patients; only five of these patients survived. The other subgroup of 11 patients received only supportive therapy. Most of the patients from this subgroup had a prolonged and complicated hospital course; only nine patients survived. Follow-up colonoscopies were performed only in five patients (out of the 14 patients who survived). In four of these patients, chronic mucosal inflammatory changes were noted.

CONCLUSIONS

Cytomegalovirus colitis occurs rarely in adult individuals. The disease may have various and multiple acute and/or chronic clinical manifestations. Clinical awareness of this condition is needed.

Hemobilia caused by cytomegalovirus cholangiopathy

A 57-yr-old male on long-term steroid therapy presented with hematemesis, fever, and a retroperitoneal fluid collection. Hemobilia was diagnosed, but the cause was not identified by ERCP, computed tomography, or angiography. Peroral cholangioscopy revealed multiple biliary ulcers. Cholangioscopic biopsies diagnosed cytomegalovirus (CMV) infection. Intravenous ganciclovir therapy was initiated, and was associated with cessation of bleeding. Biliary CMV disease is rare in HIV-negative persons, but should be considered in a patient with unexplained hemobilia. Cholangioscopy may be useful for diagnosis.

Cytomegalovirus cholangitis and pancreatitis in an immunocompetent patient

Cholangitis and pancreatitis associated with cytomegalovirus (CMV) infection in an immunocompetent patient is reported. Endoscopic retrograde cholangiography performed on a 55-year-old man for evaluation of the cause of jaundice and liver dysfunction revealed a distal focal irregular narrowing of the common bile duct. Microscopic findings of the resected specimen showed chronic cholangitis and CMV pancreatitis. Immunohistochemistry disclosed that epithelial cells in the inflamed bile duct were positive for CMV antigen, which was compatible with CMV cholangitis. Inflammation of the biliary tract or pancreas by CMV has been commonly reported as a complication in immunocompromised patients. Our report appears to be a rare case, but suggests that CMV cholangitis or pancreatitis should be considered in the differential diagnoses of common bile duct stenosis or pancreatitis even in immunocompetent individuals.

Bizarre stromal cells in ischemic bowel disease

The presence of bizarre stromal cells has been reported in gastrointestinal and extraintestinal lesions. We describe, for the first time, the presence of bizarre stromal cells with a cytomegalovirus (CMV)-like appearance or ganglion-like cells in 3 cases of ischemic colitis. The 3 patients were males ranging in age from 62 to 78 years, showed varying degrees of cardiovascular insufficiency, and were diagnosed with ischemic colitis. Colonic biopsies showed changes of ischemic colitis of variable severity. Common to all 3 cases, within the granulation tissue, stromal cells showed a broad spectrum of morphologic alterations, ranging from just nuclear enlargement to striking atypical features, large pleomorphic, hyperchromic nuclei, and eccentric prominent nucleoli. Occasionally, these cells displayed an eosinophilic oval nuclear inclusion, surrounded by a clear halo, resembling CMV inclusions. In conclusion, the etiopathogenesis of these cells can be partially explained by hypoxia, inflammation, regeneration/repair, and cell turnover alone or, more probably, in combination in the granulation tissue response to injury. The morphologic spectrum of bizarre stromal cells and ganglion-like cells suggests an obvious differential diagnosis, which includes carcinoma and sarcoma. The finding of enlarged cells with eccentric intranuclear eosinophilic inclusions requires the exclusion of CMV. However, immunohistochemistry, together with an awareness of those atypical stromal cells, can occur in the setting of ulceration and/or polypoid lesions, preventing an incorrect diagnosis.

The spectrum of gastric disease associated with Helicobacter pylori and other infectious gastritides

Helicobacter pylori is the most frequent infection of the stomach worldwide. Some of the people infected with H. pylori develop symptoms of dyspepsia that correlate with pathologic evidence of gastritis and peptic ulcers. In addition, H. pylori has been associated with preneoplastic lesions and with two neoplasias: intestinal-type gastric adenocarcinoma and mucosa-associated lymphoid tissue lymphoma. Rarely, gastric pathology can also be caused by other infectious agents, including fungi, other bacteria, parasites, and viruses. This review describes H. pylori-associated pathology and pathologies related to other infectious agents.