Cytomegalovirus-associated gastric ulcers in a patient with dermatomyositis treated with steroid and cyclophosphamide pulse therapy

Cytomegalovirus esophagitis developing during chemoradiotherapy for esophageal cancer: two case reports

BACKGROUND

It is well known that cytomegalovirus esophagitis occurs in immunosuppressed patients. However, few reports have described cytomegalovirus esophagitis occurring during chemoradiotherapy for esophageal cancer.

CASE PRESENTATION

We report two cases of patients with cytomegalovirus esophagitis that developed during chemoradiotherapy for esophageal cancer. Cytomegalovirus esophagitis was diagnosed based on the presence of intranuclear inclusions in tumor biopsy specimens. The two Japanese patients presented with anorexia and fever, which improved with anti-cytomegalovirus treatment, and intranuclear inclusions were no longer seen in the specimens.

CONCLUSIONS

The possibility of cytomegalovirus esophagitis must be kept in mind for patients with esophageal cancer presenting with prolonged fever or digestive symptoms while receiving chemoradiotherapy.

Cytomegalovirus-Associated Gastroduodenal Ulcers in a Patient With Functional Hypercortisolism: A Case Report

Cytomegalovirus (CMV)-associated gastroduodenal ulcers (GDU) are a rare digestive disease, which principally affect immunocompromised patients. We recently experienced CMV-associated GDU occurring in a seemingly immunocompetent patient. The rarity of such a condition was inimical to a correct clinical diagnosis.A 77-year-old woman with Alzheimer's disease was admitted to our hospital because of vomiting and anorexia. Her general condition was extremely poor due to severe dehydration. Any invasive procedures including gastroduodenal endoscopy could not be performed. Laboratory test results showed electrolyte imbalance, hyperglycemia, and hypercortisolemia. The plasma adrenocorticotropic hormone level was rather low. On her 11th day in hospital, she suddenly fell into shock status. Despite intensive care, the patient could not be rescued. An autopsy was performed and revealed that she had suffered from CMV-associated GDU and died of candidemia that invaded through the ulcer. Her adrenal glands showed neither neoplasm nor hyperplasia, suggesting that her hypercortisolism was a purely functional disorder. We concluded that the severe opportunistic infections were developed in association with functional hypercortisolism.This case suggests that functional hypercortisolism, even though transient, can cause a patient to be immunocompromised.

Overlap between dermatomyositis and ANCA vasculitides

We present the second report of the association between antineutrophil cytoplasm antibodies (ANCA)-associated vasculitis with dermatomyositis (DM). A 47-year-old woman suddenly developed rapidly progressive renal failure in the context of (DM). The kidney biopsy showed focal and segmental necrotizing glomerulonephritis with crescent formation. Cyclophosphamide treatment was commenced resulting in a significant recovery of kidney function and maintenance of recovery at 6 months. Although the pathophysiology is unknown, we hypothesize that CD8-T-deficient cells and MPO+ neutrophils in the DM lesions play an important role in the disease process.

Cytomegalovirus disease of the upper gastrointestinal tract in patients with rheumatic diseases: a case series and literature review

Cytomegalovirus disease of the upper gastrointestinal tract (CMV-UGT) is a rare but significant complication in patients with rheumatic diseases. We reviewed records for January 2004 to December 2012 and investigated the occurrence of CMV-UGT in patients with rheumatic diseases to evaluate clinical characteristics, the value of the CMV antigenemia assay, and the association between immunosuppressive therapy and CMV-UGT. Ten CMV-UGT events (six gastric ulcer, two esophagitis, one gastritis, and one duodenal ulcer) in nine patients (three rheumatoid arthritis, three systemic lupus erythematosus, one dermatomyositis, one systemic sclerosis, and one overlap syndrome) were identified based on pathology. Mean age was 66.5 (range, 53-76) years. The CMV antigenemia assay was negative in five cases (50 %). All ten cases received glucocorticoids and six (60 %) received pulsed glucocorticoids. Mean prednisolone dose was 31.3 (range, 7.5-40) mg/day at diagnosis. Concomitant immunosuppressive agents were used in eight cases (80 %). Considering other published cases, the most common immunosuppressive drug was cyclophosphamide (ten cases; 45 %). Notably, two of our patients who were treated with low-dose glucocorticoids plus other milder immunosuppressive drugs (methotrexate and cyclosporine) also developed CMV-UGT. Life-threatening complications such as massive bleeding or perforated ulcer occurred in two patients. These results suggest that patients receiving intensive immunosuppressive therapy such as high-dose glucocorticoids and cyclophosphamide are at higher risk for developing CMV-UGT. Moreover, CMV-UGT can occur even with low-dose glucocorticoid therapy and relatively mild immunosuppressive agents. The value of the CMV antigenemia assay for predicting CMV-UGT appears to be limited.

Fulminant gastrointestinal graft-versus-host disease concomitant with cytomegalovirus infection: Case report and literature review

Here, we report a case of fulminant gastrointestinal graft-versus-host disease (GI-GVHD) with cytomegalovirus (CMV) infection in 44-year-old woman. Despite the difficulties associated with the treatment of GI-GVHD and GI-CMV disease, the mucosal findings and the clinical course showed marked improvements during long-term clinical observation. The endoscopic findings were remarkable, with diffuse sloughing mucosa in the stomach and highly active inflammation and deep discrete ulcers throughout the colon. Changes in the CMV quantitative polymerase chain reaction results were correlated with the endoscopic mucosal findings and were useful for assessing the efficacy of the treatment. Although a definite diagnosis of GI-GVHD is generally made by endoscopy with biopsy, the gross appearance of this disease can vary depending on the endoscopy. In this paper, we also conduct a literature review of patients with GI-GVHD.

Endoscopic and radiographic features of gastrointestinal involvement in vasculitis

Vasculitis is an inflammation of vessel walls, followed by alteration of the blood flow and damage to the dependent organ. Vasculitis can cause local or diffuse pathologic changes in the gastrointestinal (GI) tract. The variety of GI lesions includes ulcer, submucosal edema, hemorrhage, paralytic ileus, mesenteric ischemia, bowel obstruction, and life-threatening perforation.The endoscopic and radiographic features of GI involvement in vasculitisare reviewed with the emphasis on small-vessel vasculitis by presenting our typical cases, including Churg-Strauss syndrome, Henoch-Schönlein purpura, systemic lupus erythematosus, and Behçet’s disease. Important endoscopic features are ischemic enterocolitis and ulcer. Characteristic computed tomographic findings include bowel wall thickening with the target sign and engorgement of mesenteric vessels with comb sign. Knowledge of endoscopic and radiographic GI manifestations can help make an early diagnosis and establish treatment strategy.