Treatment of AIDS-associated gastrointestinal cytomegalovirus infection with foscarnet and ganciclovir: a randomized comparison

AIDS-related gastrointestinal cytomegalovirus end-organ disease: A retrospective cohort study at a tertiary center in São Paulo, Brazil

BACKGROUND

Current information about AIDS-related gastrointestinal cytomegalovirus end-organ disease (CMV-EOD) is scarce. The objectives of this study were to identify the prevalence and main features of gastrointestinal CMV-EOD in patients with advanced HIV disease.

METHODS

Retrospective cohort study carried-out at a tertiary-care center in São Paulo, Brazil, from January to December 2019. We included hospitalized people living with HIV with gastrointestinal CMV-EOD, CD4 + count ≤100 cells/µL, and ≥ one quantitative detection of CMV DNA in plasma.

RESULTS

Ten (3.8%) of 261 cases had gastrointestinal CMV-EOD. Nine (90%) cases were men, age median (IQR) was 44 (38-54) years, and CD4 + cell count median (IQR) was 6 (7-39) cells/µL. The 10 cases had positive quantitative detection of CMV DNA in plasma with median (IQR) of 572 (103-2 981) IU/mL. The main presenting condition was esophagitis (n = 7, 2.7% cases). Eight (80%) cases received anti-CMV treatment, and one case died due to nosocomial pneumonia.

CONCLUSIONS

The prevalence of gastrointestinal CMV-EOD was 3.8%, similar to described in pre-combined antiretroviral therapy studies. Among cases with gastrointestinal CMV-EOD, all had positive quantitative detection of CMV-DNA in plasma but the values varied; esophagitis was the most common presentation, and all but one were discharged from the hospital.

Optimal duration of antiviral treatment in patients with gastrointestinal cytomegalovirus disease at a low and high risk of relapse

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.

Cytomegalovirus-associated esophageal stricture as a manifestation of the immune reconstitution inflammatory syndrome

Cytomegalovirus (CMV) esophagitis is well described in immunocompromised individuals, however, esophageal stricture due to CMV is rare. CMV disease in the setting of the immune reconstitution inflammatory syndrome (IRIS) usually takes the form of an immune-recovery uveitis or retinitis. We describe a young female patient with HIV who developed an esophageal stricture due to CMV within 6 months of starting antiretroviral therapy (ART). The patient responded well to treatment which involved 14 days of intravenous ganciclovir and esophageal dilatation. This is the first description of a patient developing gastrointestinal cytomegalovirus disease as a manifestation of IRIS.

Infections of the esophagus: an update on risk factors, diagnosis, and management

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.

Colovesical Fistula: An Unusual Complication of Cytomegalovirus Colitis

Cytomegalovirus (CMV) is a double-stranded DNA virus that is associated with clinically significant disease in patients with advanced immunosuppression, particularly those with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). End-organ disease with CMV is classically associated with a CD4 cell count less than 50 cells/microliter. CMV colitis is the second most common manifestation of end-organ disease in this patient population. CMV-associated enteric fistula is a rare complication that has been described in only a few case reports in the literature. These cases describe gastrocolic, enterocutaneous, enterocolic, rectovaginal, and colocutaneous fistulae. However, colovesical fistula has not been described previously. Here, we report the first case of CMV-associated colovesical fistula in a patient with HIV infection and AIDS.

Replication of CMV in the gut of HIV-infected individuals and epithelial barrier dysfunction

Although invasive cytomegalovirus (CMV) disease is uncommon in the era of antiretroviral therapy (ART), asymptomatic CMV coinfection is nearly ubiquitous in HIV infected individuals. While microbial translocation and gut epithelial barrier dysfunction may promote persistent immune activation in treated HIV infection, potentially contributing to morbidity and mortality, it has been unclear whether CMV replication in individuals with no symptoms of CMV disease might play a role in this process. We hypothesized that persistent CMV replication in the intestinal epithelium of HIV/CMV-coinfected individuals impairs gut epithelial barrier function. Using a combination of state-of-the-art in situ hybridization technology (RNAscope) and immunohistochemistry, we detected CMV DNA and proteins and evidence of intestinal damage in rectosigmoid samples from CMV-positive individuals with both untreated and ART-suppressed HIV infection. Two different model systems, primary human intestinal cells differentiated in vitro to form polarized monolayers and a humanized mouse model of human gut, together demonstrated that intestinal epithelial cells are fully permissive to CMV replication. Independent of HIV, CMV disrupted tight junctions of polarized intestinal cells, significantly reducing transepithelial electrical resistance, a measure of monolayer integrity, and enhancing transepithelial permeability. The effect of CMV infection on the intestinal epithelium is mediated, at least in part, by the CMV-induced proinflammatory cytokine IL-6. Furthermore, letermovir, a novel anti-CMV drug, dampened the effects of CMV on the epithelium. Together, our data strongly suggest that CMV can disrupt epithelial junctions, leading to bacterial translocation and chronic inflammation in the gut and that CMV could serve as a target for therapeutic intervention to prevent or treat gut epithelial barrier dysfunction during HIV infection.

Cytomegalovirus duodenitis associated with life-threatening duodenal hemorrhage in an immunocompetent patient: A case report

INTRODUCTION

Cytomegalovirus (CMV) is known to be opportunistic in immunocompromised patients. However, there have been emerging cases of severe CMV infections found in immunocompetent patients. Gastrointestinal (GI) CMV disease is the most common manifestation affecting immunocompetent patients, with duodenal involvement being exceedingly rare. Presented is a case of an immunocompetent patient with life-threatening bleeding caused by CMV duodenitis, requiring surgical intervention.

PRESENTATION OF CASE

A 60-year-old male with history of disseminated Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and aortic valve infective endocarditis, presented with life-threatening upper GI hemorrhage. Endoscopy revealed ulcerations, with associated generalized mucosal bleeding in the duodenum. After repeated endoscopic therapies and failed interventional-radiology arterial embolization, the patient required a duodenectomy and associated total pancreatectomy, to control the duodenal hemorrhage. Pathologic review of the surgical specimen demonstrated CMV duodenitis. Systemic ganciclovir was utilized postoperatively.

DISCUSSION

GI CMV infections should be on the differential diagnosis of immunocompetent patients presenting with uncontrollable GI bleeding, especially in critically ill patients due to transiently suppressed immunity. Endoscopic and histopathological examinations are often required for diagnosis. Ganciclovir is first-line treatment. Surgical intervention may be considered if there is recurrent bleeding and CMV duodenitis is suspected because of high potential for bleeding-associated mortality.

CONCLUSION

Presented is a rare case of life-threatening GI hemorrhage caused by CMV duodenitis in an immunocompetent patient. The patient failed endoscopic and interventional-radiology treatment options, and ultimately stabilized after surgical intervention.

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.

Small bowel perforation due to CMV enteritis infection in an HIV-positive patient

BACKGROUND

Cytomegalovirus infection of the gastrointestinal tract is common and is more often seen in patients with acquired immunodeficiency syndrome (AIDS). Although small bowel infection is less common than infection of other parts of the gastrointestinal system, it may lead to perforation, an acute complication, with dreadful results.

CASE PRESENTATION

This article reports a case of Cytomegalovirus ileitis with multiple small bowel perforations in a young man with human immunodeficiency virus (HIV) infection. The patient developed abdominal pain with diarrhea and fever, and eventually acute abdomen with pneumoperitoneum. The patient had poor prognosis and deceased despite the prompt surgical intervention and the antiviral therapy he received. At pathology a remarkable finding was the presence of viral inclusions in smooth muscle fibers. The destruction of muscle cells was the main cause of perforation.

CONCLUSION

Morbidity and mortality associated with perforation from CMV enteritis in AIDS patients are high and the life expectancy is short. Cytomegalovirus disease is multifocal; therefore, excision of one portion of the gastrointestinal tract may be followed by a complication elsewhere. Our case elucidate that muscle cell destruction by the virus is a significant cause leading to perforation.

Cytomegalovirus infection and the gastrointestinal tract

Cytomegalovirus (CMV) infection is common worldwide, but the majority are asymptomatic. However, during initial infection or reactivation, CMV can cause tissue-invasive end-organ damage including in the gastrointestinal tract, especially in immunocompromised individuals. Gastrointestinal CMV disease can present with myriad of symptoms and be highly variable endoscopically. In this article we review the manifestations of CMV infection within the luminal gastrointestinal tract and discuss the options for diagnosis and management.

Human immunodeficiency virus-associated gastrointestinal disease: common endoscopic biopsy diagnoses

THE GASTROINTESTINAL (GI) TRACT IS A MAJOR SITE OF DISEASE IN HIV INFECTION: almost half of HIV-infected patients present with GI symptoms, and almost all patients develop GI complications. GI symptoms such as anorexia, weight loss, dysphagia, odynophagia, abdominal pain, and diarrhea are frequent and usually nonspecific among these patients. Endoscopy is the diagnostic test of choice for most HIV-associated GI diseases, as endoscopic and histopathologic evaluation can render diagnoses in patients with non-specific symptoms. In the past three decades, studies have elucidated a variety of HIV-associated inflammatory, infectious, and neoplastic GI diseases, often with specific predilection for various sites. HIV-associated esophageal disease, for example, commonly includes candidiasis, cytomegalovirus (CMV) and herpes simplex virus (HSV) infection, Kaposi's sarcoma (KS), and idiopathic ulceration. Gastric disease, though less common than esophageal disease, frequently involves CMV, Mycobacterium avium-intracellulare (MAI), and neoplasia (KS, lymphoma). Small bowel biopsies and intestinal aspirates from HIV-infected patients often show HIV enteropathy, MAI, protozoa (Giardia, Isospora, Cryptosporidia, amebae, Microsporidia), and helminths (Strongyloides stercoralis). Colorectal biopsies demonstrate viral (CMV, HSV), bacterial (Clostridia, Salmonella, Shigella, Campylobacter), fungal (cryptococcosis, histoplasmosis), and neoplastic (KS, lymphoma) processes. Herein, we review HIV-associated GI pathology, with emphasis on common endoscopic biopsy diagnoses.

The gastrointestinal complications of oncologic therapy

A spectrum of oncologic treatments including chemotherapy, radiotherapy, and molecular targeted therapies is available to combat cancer. These treatments are associated with adverse effects in several organ systems including the gastrointestinal (GI) tract. The immunocompromised state induced by oncologic therapy is also an important contributing factor underlying GI complications. This review discusses common GI complications that can result from cancer therapy. The pathologic mechanisms underlying each complication and the pharmacology of the agents used to treat these complications are discussed.

Idiopathic AIDS enteropathy and treatment of gastrointestinal opportunistic pathogens

Diarrhea in patients with acquired immune deficiency syndrome (AIDS) has proven to be both a diagnostic and treatment challenge since the discovery of the human immunodeficiency virus (HIV) virus more than 30 years ago. Among the main etiologies of diarrhea in this group of patients are infectious agents that span the array of viruses, bacteria, protozoa, parasites, and fungal organisms. In many instances, highly active antiretroviral therapy remains the cornerstone of therapy for both AIDS and AIDS-related diarrhea, but other targeted therapies have been developed as new pathogens are identified; however, some infections remain treatment challenges. Once identifiable infections as well as other causes of diarrhea are investigated and excluded, a unique entity known as AIDS enteropathy can be diagnosed. Known as an idiopathic, pathogen-negative diarrhea, this disease has been investigated extensively. Atypical viral pathogens, including HIV itself, as well as inflammatory and immunologic responses are potential leading causes of it. Although AIDS enteropathy can pose a diagnostic challenge so too does the treatment of it. Highly active antiretroviral therapy, nutritional supplementation, electrolyte replacements, targeted therapy for infection if indicated, and medications for symptom control all are key elements in the treatment regimen. Importantly, a multidisciplinary approach among the gastroenterologist, infectious disease physician, HIV specialists, oncology, and surgery is necessary for many patients.

Cytomegaloviral colitis in HIV positive patients: endoscopic findings

BACKGROUND

Diarrhea in seropositive human immunodeficiency virus patients is one of the most important and disabling symptoms, and often decreases their quality of life. Cytomegalovirus colitis is among the principal causes of this symptom and colonoscopy is the gold standard examination to diagnose it.

AIM

To define the main endoscopic findings in seropositive human immunodeficiency virus patients with cytomegalovirus colitis.

METHODS

Two hundred and forty-three colonoscopies were performed in 200 seropositive human immunodeficiency virus patients with diarrhea associated or not to abdominal pain or gastrointestinal bleeding, over 10-year period, whom 51 patients were diagnosed with cytomegalovirus colitis. Full length colonoscopy with ileum intubation was always tried and multiple biopsies of all segments examined, including endoscopically normal segments, were attempted. All diagnoses were confirmed by histologic and immunohistochemical studies.

RESULTS

Total colonoscopy was possible in 98.03% and ileum intubation in 88.23% of these cytomegalovirus colitis patients. At colonoscopy, a heterogeneous ulcerative pattern was presented in 72.54%, an inflammatory process of the mucosa in 21.56% and 5.88% of the patients mucosa was endoscopically normal.

CONCLUSION

Full length colonoscopy with ileum intubation and multiples biopsies of all segments, even when they are endoscopically normal, have always to be attempted in cases of seropositive human immunodeficiency virus patient with diarrhea.

Gastrointestinal complications of oncologic therapy

Gastrointestinal complications are common in patients undergoing various forms of cancer treatment, including chemotherapy, radiation therapy, and molecular-targeted therapies. Many of these complications are life-threatening and require prompt diagnosis and treatment. Complications of oncologic therapy can occur in the esophagus (esophagitis, strictures, bacterial, viral and fungal infections), upper gastrointestinal tract (mucositis, bleeding, nausea and vomiting), colon (diarrhea, graft-versus-host disease, colitis and constipation), liver (drug hepatotoxicity and graft-versus-host disease), and pancreas (pancreatitis). Treatment of the different gastrointestinal complications should be tailored to the individual patient and based on the underlying pathophysiology of the complication.

Cytomegalovirus colitis in a critically ill patient following elective repair of an abdominal aortic aneurysm

We describe a case of cytomegalovirus colitis in a critically ill but otherwise immunocompetent 61-year-old male. Infection was demonstrated by histology and confirmed by plasma polymerase chain reaction and detection of cytomegalovirus IgM antibody. The patient was treated with ganciclovir with resolution of the cytomegalovirus viraemia. Cytomegalovirus colitis may be an under-recognised problem in immunocompetent patients who are critically ill. Quantification of plasma cytomegalovirus DNA by polymerase chain reaction is a non-invasive method of supporting the diagnosis and can be used to monitor the treatment of cytomegalovirus infection in the immunocompetent.

[Pneumonias and immunosuppression]

Pneumonias are common, life threatening complications in immunodeficient patients. A rapid, targeted diagnosis and therapy are decisive for the course of the disease. The etiological spectrum is substantially broader than for immunocompetent patients. Important indications are provided by the type and intensity of the immunosuppression, gaps in the prophylactic concept and particular exposures. For diagnostic planning, high resolution computed tomogram of the thorax is necessary. The standard method for isolating the pathogen is flexible bronchoscopy with bronchoalveolar lavage. Indications for invasive bioptic measures depend on the individual situation, the expected spectrum of pathogens as well as risk factors and adverse effects. Non-invasive antigen and PCR tests complement the diagnostic spectrum, especially for difficult to cultivate pathogens such as fungi and Herpes viruses. The selection of the initial, targeted antimicrobial therapy is based on guidelines. The treatment should be followed after obtaining the relevant microbiological data.

A contributive result of open-lung biopsy improves survival in acute respiratory distress syndrome patients

OBJECTIVE

The impact of a contributive result of open-lung biopsy on the outcome of patients with acute respiratory distress syndrome (ARDS) has not been extensively investigated. The aim of this study was therefore to determine the rate of contributive open-lung biopsy and whether it improved the prognosis of ARDS patients.

DESIGN

Prospective study conducted during an 8-yr period.

SETTING

A 14-bed medico-surgical intensive care unit and a 12-bed medical intensive care unit from the same hospital.

PATIENTS

One hundred open-lung biopsies were performed in 100 patients presenting ARDS.

INTERVENTIONS

Open-lung biopsy was performed after > or = 5 days of evolution of ARDS when there was no improvement in the respiratory status despite negative microbiological samples cultures and potential indication for corticosteroid treatment.

MEASUREMENTS AND MAIN RESULTS

Ten patients presented a mechanical complication following open-lung biopsy (two pneumothoraces and eight moderate air leaks). The unique independent factor associated with this complication was the minute ventilation when open-lung biopsy was performed (odds ratio, 1.20; 95% confidence interval, 1.03-1.41; p = .02). Fibrosis was noted in 53 patients but was associated with an infection in 29 of these 53 patients (55%). A contributive result of open-lung biopsy (defined as the addition of a new drug) was noted in 78 patients. Simplified Acute Physiology Score II was the only independent predictive factor of a contributive open-lung biopsy (odds ratio, 0.96; 95% confidence interval, 0.92-0.99; p = .04). Survival was higher in patients with a contributive open-lung biopsy (67%) than in patients in whom open-lung biopsy results did not modify the treatment (14%) (p < .001). The factors predicting survival were a contributive result of open-lung biopsy, female gender, and the Organ System Failures score the day of open-lung biopsy.

CONCLUSIONS

The present study shows that open-lung biopsy provided a contributive result in 78% of ARDS patients with a negative bronchoalveolar lavage. Survival of ARDS patients improved when open-lung biopsy was contributive.

A case of destructive Wegener's granulomatosis complicated by cytomegalovirus infection

BACKGROUND

A 63-year-old man with a 4-year history of Wegener's granulomatosis presented with hemoptysis, palatal ulceration and sensorimotor polyneuropathy.

INVESTIGATIONS

Physical examination, serologic testing, proteinase 3 enzyme-linked immunosorbent assay, IgG and IgM specific to Epstein-Barr virus enzyme-linked immunosorbent assay, MRI of the middle face, an ear, nose and throat consultation, immunohistochemical staining of an esophageal sample obtained from esophagogastroduodenoscopy, polymerase chain reaction of cytomegalovirus (CMV) DNA from esophageal and blood samples, and measurement of pp65 early antigen.

DIAGNOSIS

Wegener's granulomatosis with progressive palatal ulceration and osseous destruction complicated by CMV-related esophagitis during induction treatment.

MANAGEMENT

Induction treatment with cyclophosphamide pulse therapy was discontinued and antiviral therapy with ganciclovir was started. Cyclophosphamide pulse therapy was later reintroduced, but there was subsequent CMV reactivation, and, therefore, cyclophosphamide pulse therapy was suspended again and ganciclovir and intravenous immunoglobulin were started. After control of CMV, cyclophosphamide pulse therapy was reinitiated. Prolonged immunosuppressive therapy controlled disease activity, without CMV reactivation.

Diarrhea in patients with AIDS

Diarrhea in patients with AIDS is a worldwide problem that can have a devastating impact on quality of life for the patient. Chronic diarrhea, usually defined as at least 4 weeks' duration, is more common in patients with low CD4-positive T-lymphocyte counts, signaling advanced immunosuppression. Some organisms, such as Microsporidia, usually cause diarrhea only in the immunosuppressed; others, such as Cryptosporidium, Salmonella, Shigella, and Campylobacter, which are capable of causing diarrhea in the immunocompetent population, produce more severe or prolonged infections in people living with AIDS. Familiarity with the most common pathogens in the clinician's region will help with diagnosis and treatment. Because treatment options vary widely depending upon the infectious agent, thorough microbiologic evaluation is warranted. A stepped diagnostic approach of stool cultures and specialized microscopy and stains for protozoa, followed by sigmoidoscopy or colonoscopy and duodenoscopy with biopsies for histopathological examination is recommended in all patients with persistent, disabling diarrhea who have a CD4 count of less than 200/mm3, and should be considered for those with higher counts on an individual basis. Treatment, tailored to the specific pathogen, may need to be prolonged in the most severely immunocompromised patients to prevent relapse or recrudescence. For patients taking antiretroviral therapy (especially protease inhibitors) in whom no infectious agent can be found, diarrhea may be due to the medications. Nonspecific antidiarrheal agents should be tried until one that suits the patient is found. The most essential component of any therapeutic strategy for a patient with AIDS-associated diarrhea is restoration of the underlying immunologic defect using highly active antiretroviral therapy.

Canadian consensus guidelines for the management of cytomegalovirus disease in HIV/AIDS

BACKGROUND

The management of HIV-infected patients with cytomegalovirus (CMV) disease has changed significantly with the availability of highly active antiretroviral therapy (HAART).

OBJECTIVES

These updated guidelines are intended to provide practical help to physicians managing HIV-positive patients with or at risk for CMV disease.

METHODS

The 10 members of the Canadian CMV Disease in HIV/AIDS Consensus Group were infectious disease specialists, a primary care physician and ophthalmologists with expertise in HIV and CMV infection. Financial support by Hoffmann-La Roche Canada Ltd was unrestricted, and was limited to travel expenses and honoraria. The consensus group met in June and October 2002. Key areas to be considered were identified, and group members selected, reviewed and presented relevant recent literature for their assigned section for the group's consideration. Evidence was assessed based on established criteria, which were expert opinions of the members. Draft documents were circulated to the entire group and modified until consensus was reached. The final guidelines represent the group's consensus agreement. The guidelines were approved by the Canadian Infectious Disease Society.

RESULTS AND CONCLUSIONS

The guidelines address symptom monitoring, screening for early detection and prevention, and treatment using oral, intravenous and intraocular anti-CMV therapies in conjunction with HAART.

Cytomegalovirus ischemic colitis: a near-fatal presentation of HIV infection

Cytomegalovirus infection occurs in immunocompromised patients. We present a 45-year-old male with no prior medical history who presented to the hospital with weight loss and non-bloody diarrhea. During hospitalization, he developed severe hematochezia and hypotension. Colonoscopy revealed dusky, friable mucosa. The patient arrested and was resuscitated. Specimen from emergent colectomy showed ischemic changes secondary to cytomegalovirus infection of endothelium and small-vessel thrombosis. An HIV test was subsequently positive with CD4 count of 2 per microliter. The patient was treated with antiretroviral therapy and ganciclovir. He survived postoperative infections and was eventually discharged. In summary, this case of near-fatal cytomegalovirus colitis represents an unusual presentation of undiagnosed HIV infection. Cytomegalovirus infection should be included in the differential diagnosis of immunocompromised patients with gastrointestinal symptoms. Hematochezia may be from intestinal ulceration or severe ischemic damage. Antiretroviral therapy and ganciclovir or foscarnet should be initiated promptly. Surgery is indicated in life-threatening hemorrhage or obvious bowel necrosis.

Low prevalence of Helicobacter pylori but high prevalence of cytomegalovirus-associated peptic ulcer disease in AIDS patients: Comparative study of symptomatic subjects evaluated by endoscopy and CD4 counts

BACKGROUND AND AIMS

The role of Helicobacter pylori infection in gastroduodenal lesions might be different between the general population and AIDS patients. The aim of the present study was to compare the prevalence of H. pylori and cytomegalovirus (CMV) infection in AIDS patients and HIV-negative controls. The impact of CD4 lymphocyte counts on H. pylori and CMV infection in the same subjects was also assessed.

METHODS

One hundred and fifty-six patients (52 HIV-positive, 104 HIV-negative) with gastrointestinal symptoms were evaluated with upper gastrointestinal endoscopy and biopsy. Comparison of the prevalence of H. pylori and CMV infection was made by dividing AIDS patients into two groups: those with CD4 counts >100/mm3 and those with CD4 counts <100/mm3, and ulcer and non-ulcer patients.

RESULTS

In comparison with HIV-negative controls, AIDS patients had a lower prevalence of H. pylori infection (P < 0.0001) but a higher prevalence of CMV infection (P < 0.0001). Cytomegalovirus infection was frequently found in AIDS patients with CD4 count <100/mm3, in comparison with those with a CD4 count >100/mm3. In AIDS patients, CMV was more frequently detected in subjects with peptic ulcers (P = 0.0125). Conversely, the prevalence of H. pylori infection in AIDS patients was not different between those with and without peptic ulcers.

CONCLUSIONS

The low prevalence of H. pylori infection and peptic ulcer in AIDS patients suggests a different role of H. pylori infection in peptic ulcer or even a different mechanism of peptic ulcerogenesis in HIV-positive subjects. Cytomegalovirus, rather than H. pylori, may be the main causative pathogen of peptic ulcers in AIDS patients.

CMV enteritis causing ileal perforation in underlying lupus enteritis

We report a case of cytomegalovirus (CMV) enteritis in a 31 year-old -woman with lupus enteritis. In August 2002 the patient complained of severe abdominal pain. An abdominopelvic CT scan at the time showed free air in the peritoneal cavity and wall thickening of the ileal loop. She was diagnosed as having panperitonitis due to an ileal perforation, and underwent an emergency laparotomy. The surgical specimen revealed CMV inclusion bodies in the infarcted lesion. Her symptoms improved following the initiation of ganciclovir therapy. To the best of our knowledge, this is the first report in the English literature of an ileal perforation due to CMV infection in a patient with lupus enteritis.

Cytomegalovirus Disease in the Highly Active Antiretroviral Therapy Era

Cytomegalovirus (CMV) is a major cause of morbidity and mortality in AIDS patients. Epidemiologic studies indicate that until 10 years ago, nearly one half of HIV-infected patients eventually developed CMV end-organ disease, including chorioretinitis, esophagitis, colitis, pneumonia, and central nervous system disease. Since the introduction of highly active antiretroviral therapy (HAART) this incidence has declined dramatically. Nonetheless, patients still present with CMV disease and resistance or intolerance to HAART does develop, which may give rise to a resurgence of CMV syndromes in AIDS patients. Until recently, only intravenous ganciclovir and foscarnet were available for management of CMV infection. With the advent of additional agents, clinicians now face the challenge of optimizing therapy for individual patients. This paper reviews the most common clinical syndromes caused by CMV, the treatment options, as well as an approach to diagnosing and treating antiviral resistance.

The human cytomegalovirus

Human cytomegalovirus (HCMV), a betaherpesvirus, represents the major infectious cause of birth defects, as well as an important pathogen for immunocompromised individuals. The viral nucleocapsid containing a linear double-stranded DNA of 230 kb is surrounded by a proteinaceous tegument, which is itself enclosed by a loosely applied lipid bilayer. Expression of the HCMV genome is controlled by a cascade of transcriptional events that leads to the synthesis of three categories of viral proteins designated as immediate-early, early, and late. Clinical manifestations can be seen following primary infection, reinfection, or reactivation. About 10% of infants are infected by the age of 6 months following transmission from their mothers via the placenta, during delivery, or by breastfeeding. HCMV is a significant post-allograft pathogen and contributes to graft loss independently from graft rejection. Histopathologic examination of necropsy tissues demonstrates that the virus enters via the epithelium of the upper alimentary, respiratory, or genitourinary tracts. Hematogenous spreading is typically followed by infection of ductal epithelial cells. Infections are kept under control by the immune system. However, total HCMV clearance is rarely achieved, and the viral genome remains at selected sites in a latent state. Virological and molecular detection of HCMV, as well as serological demonstration of a specific immune response, are used for diagnosis. Treatment of HCMV infections is difficult because there are few options. The presently available drugs produced a significant clinical improvement, but suffer from poor oral bioavailability, low potency, development of resistance in clinical practice, and dose-limiting toxicities.

Cytomegalovirus-associated manifestations involving the digestive tract in children with human immunodeficiency virus infection

OBJECTIVE

To study the clinical manifestations of gastrointestinal cytomegalovirus disease in children with human immunodeficiency virus infection.

METHODS

Review of clinical records of eight human immunodeficiency virus-infected children and histopathologically confirmed gastrointestinal cytomegalovirus disease from 1995 to 2001.

RESULTS

Six of the eight children were younger than 1 year. The most common clinical presentations were fever and chronic diarrhea. Lower gastrointestinal hemorrhage and bowel perforation were noted in four and three patients, respectively. The colon was the most commonly affected site, followed by the small bowel and esophagus. The diagnosis was established by histopathology, obtained during endoscopy and surgery. Mucosal edema, erythema, and ulcer comprised the most common endoscopic findings. Two patients with fever, chronic diarrhea, and lower gastrointestinal bleeding developed remission after being treated with a 14-day course of ganciclovir.

CONCLUSION

Gastrointestinal cytomegalovirus disease can result in serious life-threatening complications, such as bowel perforation and massive gastrointestinal bleeding. Patients with chronic diarrhea and fever of unidentified cause might benefit from gastrointestinal endoscopy for early diagnosis and treatment. Although ganciclovir does not eradicate the infection and relapses are frequent, this treatment can prevent complications and reduce morbidity.

AIDS related opportunistic infections, going but not gone

It is now more than two decades since the AIDS epidemic began with a cluster of Pneumocystis carinii pneumonia (PCP) in a community of homosexual men. Since then, many other infections have been characterized as opportunistic infections secondary to HIV infection. These include, but are not limited to, infections with Toxoplasma gondii, Cytomegalovirus (CMV), Mycobacterium avium complex (MAC), and Cryptococcus neoformans. Over the last two decades, there have been dramatic improvements in diagnosis, prevention and treatment of all these infections. As a result, in North America and Western Europe the rates of opportunistic infections secondary to AIDS have decreased substantially. We will review these common opportunistic infections below.

Cytomegalovirus treatment options in immunocompromised patients

Cytomegalovirus (CMV) infection was recognised in congenitally infected infants in the first half of the 20th century. Following the increased use of immunosuppressive regimens for bone marrow and solid organ transplantation, various manifestations of CMV disease were recognised. Milder symptoms included fever, anorexia and malaise but severe symptoms included pneumonitis, hepatitis, gastrointestinal ulceration, choreoretinitis and encephalopathy, all with a high morbidity or mortality. With the onset of the AIDS epidemic, manifestations of CMV became evident, predominantly retinitis. Ganciclovir used intravenously has been the principal anti-CMV agent investigated. However, ganciclovir has problems with suboptimal efficacy, toxicity, poor oral bioavailability and evolution of resistant strains. Additional studies have been performed on foscarnet and cidofovir, although the use of both have been limited by their nephrotoxicity. Combination therapy with ganciclovir and foscarnet for resistant strains has been used. There are promising newer drugs like the methylenecyclopropane nucleoside analogues and benzimidazole. The most novel compound is the antisense oligonucleotide fomivirsen that has been evaluated principally in CMV retinitis. The role of immunotherapy with either immunoglobulin prophylaxis or the novel adoptive immunotherapy needs further evaluation.

Small Intestinal Infections

The differential diagnosis of small intestinal infections is broad, making the identification and management of these disorders challenging. The majority of cases of acute diarrhea are self-limited and do not require diagnostic evaluation or treatment. Most patients do not require specific therapy, and treatment should focus on fluid and electrolyte replacement. In patients with severe, persistent, or chronic diarrhea, a careful medical history and routine stool testing are helpful in determining the cause. Pathogen-specific therapy should be given in patients in whom a pathogen is identified. In those without an identifiable pathogen, antidiarrheal agents are helpful in reducing the number of bowel movements and preventing further dehydration. Endoscopy may be helpful in patients with severe diarrhea and a negative stool evaluation, particularly in HIV-infected patients with chronic diarrhea. Surgery has a limited role in the management of small intestinal infections, but may be lifesaving in patients with intestinal perforation or small bowel obstruction.

Enteric viruses in HIV-related diarrhoea

HIV-related diarrhoea is an important cause of morbidity and mortality in HIV infection. Cytomegalovirus is a well-established cause of diarrhoea, but the role of other enteric viruses is less clear and will be discussed here. The clinical manifestations, disease mechanisms, diagnostic techniques and current treatments for the management of these infections are reviewed.

Outcome of AIDS-associated cytomegalovirus colitis in the era of potent antiretroviral therapy

The effect of protease inhibitors (PIs) on the outcome of AIDS-associated cytomegalovirus (CMV) colitis is unknown. The aim of this study was to determine the impact of PIs on the recurrence of CMV disease and long-term survival in a large cohort of acquired immunodeficiency syndrome (AIDS) patients with CMV colitis. We reviewed the medical records of 252 AIDS patients who were diagnosed with CMV colitis by colonoscopy between January 1992 and January 1997 at Bellevue Hospital (New York, NY, U.S.A.). Follow-up data were obtained from chart review and direct telephone contact. A complete response to ganciclovir and/or foscarnet therapy was seen in 87.0% of the patients. Recurrence of CMV colitis occurred in 53.1% of patients and was significantly less common in those who received maintenance therapy (36.1% vs. 56.7%; p = 0.03) and in those who were treated with PIs (22.8% vs. 71.9%; p < 0.001). During follow-up. 69.3% of patients died. Multivariate analysis using Cox regression showed that mortality was increased in patients with recurrent CMV colitis (relative risk [RR] of death, 1.7: 95% CI, 1.1-2.6; p = 0.02) and comorbid disease (RR, 1.5: 95% CI, 1.1-2.2; p = 0.02), and decreased in those who were treated with PIs (RR, 0.42; 95% CI, 0.3-0.7; p = 0.001). The median survival was 71 weeks and was significantly longer in patients who were treated with PIs than in those who did not receive these potent anti-retroviral medications (99 vs. 51 weeks; p < 0.001). PIs significantly improve the outcome of AIDS-associated CMV colitis.

Gastrointestinal manifestations of HIV infection

As patients with human immunodeficiency virus (HIV) infection become more immunocompromised, gastrointestinal symptoms become more common. Most symptoms result from opportunistic infections and can be diagnosed and treated by gastroenterologists, although medical microbiology and histopathology input is essential.

Esophageal disease in patients with AIDS: diagnosis and treatment

Patients with HIV infection often present with symptoms suggesting esophageal disease: these include odynophagia (pain with swallowing), dysphagia (difficulty in swallowing), and retrosternal chest pain. Esophageal symptoms rank second only to diarrhea in frequency of gastrointestinal complaints among patients with AIDS. Also, esophageal opportunistic infections have been associated with a poor outcome, the mean survival after diagnosis being less than 6 months in one study. Such short survival may be explained by the underlying immunosuppression, as well as a decrease in nutritional intake due to difficulty swallowing.

Small intestine pathogens in AIDS: conventional and opportunistic

The small intestine, coming in direct contact with ingested potential pathogens, depends on active mucosal immunity to withstand invasion and damage. In patients with AIDS and severe impairment of immunoregulatory lymphocytes, proliferation of protozoal, viral, bacterial, and fungal pathogens produces diarrhea and malabsorption. When noninvasive tests of stool and blood fail to identify responsible organisms, endoscopy can reveal mucosal lesions which are suggestive if not diagnostic. Cryptosporidium, cf2E. intestinalis, cf1CMV, MAC, and other infections can be identified by intestinal biopsy quicker and often at lower overall cost than they can be by culture.

Diagnosis and treatment of colonic disease in AIDS

The colon is a frequent site of gastrointestinal complications in patients with HIV infection, and these colonic disorders increase in frequency as immunodeficiency worsens. The most common clinical manifestations of colonic disease in AIDS are diarrhea, lower gastrointestinal bleeding, and abdominal pain. Toxic megacolon, intussuseption, typhlitis, idiopathic colonic ulcer, and pneumatosis intestinalis also have been described. In the HIV-infected patient with preserved immunity, the most common cause of colitis is bacterial, but as the degree of immunodeficiency worsens, opportunistic pathogens (CMV, protozoa, mycobacteria, fungi) and neoplasms become more frequent. The frequent use of antibiotics, chemotherapeutic agents, and frequent hospitalization increase the susceptibility to cf2Clostridium difficule cf1colitis. Endoscopy plays an integral role in the management of many colonic disorders in AIDS.

Risk of developing CMV retinitis following non-ocular CMV end organ disease in AIDS patients

AIM

To describe the risk of developing cytomegalovirus (CMV) retinitis after a first episode of extraocular CMV disease in AIDS patients.

METHODS

A review of the clinical records of 20 AIDS patients, without CMV retinitis, with histologically confirmed extraocular CMV disease, was performed. The main outcome measures were occurrence of CMV retinitis, time to development of CMV retinitis, relation to maintenance therapy, and survival.

RESULTS

A CMV retinitis was diagnosed in 17 of 20 (85%) patients with an immunohistologically confirmed diagnosis of extraocular CMV disease after a mean follow up of 6.4 months. Four patients received maintenance therapy. Three of them developed retinitis after a mean of 9.6 months (range 2-16 months). Sixteen did not receive maintenance and retinitis was diagnosed in 14 of them after a mean of 5.7 months (range 2-11 months). Mean survival was 9.9 months after the diagnosis of extraocular disease, and 4.5 months after the diagnosis of retinitis. In the four patients receiving maintenance therapy, mean survival was 11.5 months, and in the 16 other patients mean survival was 9.5 months. Patients did not receive protease inhibitors.

CONCLUSION

In the preprotease inhibitor era extraocular CMV disease strongly predisposes to the subsequent development of CMV retinitis. Although maintenance therapy did not prevent the occurrence of retinitis, the time period between both events seems to lengthen considerably. In patients receiving maintenance survival is also longer.

Cytomegalovirus colitis in acquired immunodeficiency syndrome: a clinical and endoscopic study

BACKGROUND

Cytomegalovirus colitis is an important complication of the acquired immunodeficiency syndrome (AIDS), although the clinical and colonoscopic manifestations of this disease have not been systematically characterized.

METHODS

Patients with AIDS and cytomegalovirus colitis were prospectively identified at two medical centers. The diagnosis of cytomegalovirus disease was based on established endoscopic and histologic criteria. At the time of sigmoidoscopic and/or colonoscopic examination, clinical features were recorded; the location, size, and appearance of all endoscopic abnormalities were documented; and multiple biopsies of any lesions were performed.

RESULTS

Fifty-six patients were studied. The majority of the patients were homosexual men with severe immunodeficiency (median CD4 lymphocyte count 15/mm3, range 1 to 294/mm3). Chronic diarrhea and abdominal pain were the most frequent clinical manifestations, seen in 45 (80%) and 28 (50%) patients, respectively. Five patients (9%) presented with lower gastrointestinal hemorrhage, three of whom had no antecedent history of diarrhea. The colonoscopic abnormalities could be categorized into three main groups: colitis associated with ulcer (39%), ulceration alone (38%), or colitis alone (20%). Subepithelial hemorrhage was a prominent endoscopic manifestation of disease. Of the 31 patients undergoing colonoscopy to the cecum, in four (13%) endoscopic evidence of disease was limited to the colon proximal to the splenic flexure.

CONCLUSIONS

Cytomegalovirus colitis in AIDS appears to have variable but stereotypical clinical and colonoscopic manifestations. Distal colitis associated with ulceration is the most common colonoscopic pattern.

Prevalence and etiology of gastroduodenal ulcer in HIV-positive patients: a comparative study of 497 symptomatic subjects evaluated by endoscopy

OBJECTIVE

In 497 HIV-positive (+) patients with upper digestive tract symptoms, 23 (5%) had gastroduodenal ulcers (GDU) at upper endoscopy.

METHODS

To establish the causes of GDU in this setting, 16 of these patients who had had comprehensive histological evaluation (group I) were compared with 20 HIV+ subjects with upper gastrointestinal symptoms but without ulcer (group II), and with 16 seronegative patients with GDU (group III). Eighty-one percent of group I subjects and 90% of group II patients had C3 AIDS. The presence of gastritis and Helicobacter pylori, fungi, mycobacteria, viruses (especially cytomegalovirus [CMV] and herpes simplex [HSV]), and parasites was determined in all three groups by histopathological and microbiological studies.

RESULTS

The prevalence of chronic active gastritis was 13/16 (81%) in group I, 12/20 (60%) in group II, and 15/16 (94%) in group III. It was associated with H. pylori in group III, and with opportunistic pathogens in groups I and II and with none in group III. H. pylori was detected in 5/16 patients (31%) in group I, in 12/20 (60%) in group II, and 11/16 (69%) in group III. Cytomegalovirus was histologically diagnosed in 8/16 patients (50%) in group I and in 1/20 (5%) in group II. This virus was the only factor shown to be significantly associated with GDU in these cases (p = 0.0046). Cryptosporidium was found in 2/16 (12.5%) patients in group I, in 1/20 (5%) in group II, and in none in group III. Differences between groups I and II were not statistically significant. No other organisms were observed in the three groups.

CONCLUSIONS

Gastroduodenal ulcers were infrequent in HIV+ subjects with upper digestive tract symptoms and CMV was the only organism significantly associated with GDU in HIV+ patients. Among HIV+ patients, H. pylori was an uncommon cause of ulcer. Among HIV+ subjects with ulcer, chronic active gastritis was more common than H. pylori and it was associated with other pathogens. Finally, HIV+ patients with GDU should have endoscopic biopsies to detect opportunistic infections, especially CMV, because H. pylori infection is uncommon.