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

Are children with protein-losing enteropathy after the Fontan operation at increased risk of cytomegalovirus enteropathy? A report of two cases

INTRODUCTION

Aetiology of protein-losing enteropathy in single-ventricle type CHD is multi-factorial.

REPORT

We describe two Fontan patients with protein-losing enteropathy who presented with cytomegalovirus-associated colitis.

DISCUSSION

Fontan patients display risk factors for cytomegalovirus-induced gastroenteropathy that may affect lymph angiogenesis, disease development, and progression.

CONCLUSION

Cytomegalovirus enteropathy may be common among Fontan patients who suffer from protein-losing enteropathy. Polymerase chain reaction is important for detection.

Surgical manifestations of gastrointestinal cytomegalovirus infection in children: Clinical audit and literature review

INTRODUCTION

Gastrointestinal sequelae of cytomegalovirus are rare, usually associated with significant immune compromise, and carry a high morbidity and mortality. Gastrointestinal disease frequently requires surgical intervention for diagnosis and management.

AIM

The aim of the study is to evaluate the incidence, presentation and management of gastrointestinal cytomegalovirus disease in a pediatric population.

METHOD

Between January 2003 and June 2011, a retrospective folder review was conducted of all symptomatic children with proven CMV disease, presenting to the surgical service. Eligible patients were identified using the surgical, histopathology and serology databases.

RESULTS

Thirty-eight patients (1.8/1000 surgical admissions) were identified with a median presenting age of 5months (range 3days-12years). Esophagitis (n=18) and small bowel disease (n=16) predominated, but CMV was seen throughout the gastrointestinal tract. Risk factors included HIV infection (n=21, 55%) and recent gastrointestinal surgery or infection (n=10, 26%). Characteristic multiple jejunoileal perforations were seen in six patients. Compared to upper GIT disease, intestinal involvement was associated with younger age and doubled mortality. In HIV-infected children, median CD4 (%) was lower in intestinal compared to upper gastrointestinal disease. Morbidities included anastomotic breakdowns (5), anastomotic strictures (3), relook laparotomies (10), resistant esophageal strictures (5) and prolonged parenteral nutrition (5). Anti-CMV drugs were given in 63%. Overall mortality was 32% (12/38) and was associated with lower GIT disease.

CONCLUSION

Invasive CMV gastrointestinal disease in our children was predominantly HIV-associated, or followed a major lower gastrointestinal inflammatory insult in infants younger than 6months. Successful therapy requires a high index of suspicion of active CMV disease to allow early implementation of CMV viral load control and aggressive treatment of the underlying immune impairment. Multiple surgical interventions are often required for both tissue diagnosis and management of acute and chronic complications. CMV-viral-load-tailored anti-CMV therapy is supported by recent literature.

Cytomegalovirus-associated esophageal ulcer in an immunocompetent infant: When should ganciclovir be administered?

Cytomegalovirus (CMV)-associated esophageal ulcer is rare in immunocompetent infants. The presence of inclusion bodies and immunohistochemical staining for CMV in biopsy specimens obtained during esophagogastroduodenoscopy (EGD) indicate that such ulcers occur because of CMV infection. A 7-week-old female infant who experienced frequent vomiting and feeding intolerance was diagnosed with a massive CMV-associated ulcer in the distal esophagus. The ulcer improved after conservative treatment using proton-pump inhibitors; however, ganciclovir was not administered. In a follow-up EGD biopsy specimen, no CMV inclusion bodies were present, and immunohistochemical staining results for this virus were negative. The presence of CMV inclusion bodies indicates active viral replication. If persistent inclusion bodies or positive immunohistochemical staining for CMV is observed in follow-up biopsy specimens, ganciclovir may be used to treat CMV-associated esophageal ulcers.

Surgical implications of human immunodeficiency virus infections

Pediatric HIV (human immunodeficiency virus) is a pandemic predominantly in sub-Saharan Africa. Approximately 2.2 million children aged less than 15 years are infected with HIV, representing almost 95% of the total number of children globally infected with HIV. Therefore, increasing numbers of HIVi or -exposed but uninfected children can be expected to require a surgical procedure to assist in the diagnosis of an HIV/acquired immune deficiency syndrome-related complication, to address a life-threatening complication of the disease, or for routine surgery encountered in HIV-unexposed children. HIVi children may present with both conditions unique to HIV infection and surgical conditions routine in pediatric surgical practice. HIV exposure confers an increased risk of complications and mortality for all children after surgery, whether they are HIV infected or not. This risk of complications is higher in the HIVi group of patients. These findings seem to be independent of whether patients undergo an elective or emergency procedure, but the risk of an adverse outcome is higher for a major procedure. Surgical implications of HIV infection are comprehensively reviewed in this article.

Endoscopy findings in HIV-infected children from sub-Saharan Africa

BACKGROUND

The causes of persistent gastro-intestinal symptoms in HIV-infected children from sub-Saharan Africa remain poorly documented.

METHODS

The clinical, radiological and endoscopic findings of all HIV-infected children who underwent upper GI endoscopy at Red Cross Children's Hospital, Cape Town, South Africa, from February 2003 to October 2005 were documented.

RESULTS

Twenty-six HIV-infected children underwent endoscopy; median age 1 year (range: 0.17-10.9 years). The majority had advanced HIV disease; 18 (69%) were WHO Stage 4; median CD4 10.7% (range: 1-39.8%). Presenting symptoms included persistent vomiting (18), dysphagia (4) and GIT bleed (6). Observational and histological findings showed poor correlation. Pathogens were identified in 10 children: cytomegalovirus infection in seven (two with cryptosporidium co-infection), Candida in two, Helicobacter pylori in one. Age and CD4 count were not associated with the pathogens. Endoscopy findings influenced clinical management in 21 (81%) cases.

CONCLUSION

Upper-GI endoscopy identified a diverse spectrum of disease and provided information that would be clinically relevant to most HIV-infected children with upper gastro-intestinal symptoms.

The pathology of malabsorption: current concepts

Intestinal malabsorption results from a wide variety of causes, which can most easily be organized into three groups. Maldigestion arises from problems with mixing or with digestive mediators, and includes post-gastrectomy patients and those with deficiencies of pancreatic or intestinal enzymes, or of bile salts. Mucosal and mural causes of malabsorption are abundant, and include gluten-sensitive enteropathy, tropical sprue, autoimmune enteropathy, and HIV/AIDS-related enteropathy, as well as mural conditions such as systemic sclerosis. Finally, microbial causes of malabsorption include bacterial overgrowth, Whipple's disease, and numerous infections or infestations that are most frequently seen in immunocompromised patients. An overview of the most common and interesting entities in each of these categories follows, along with a discussion of current concepts. Mucosal conditions and microbial causes of malabsorption are given special attention.

Cytomegalovirus esophagitis in a child with human immunodeficiency virus-1 infection presenting as fever of unknown origin and stunted growth

We report a 12-year old boy with human immunodeficiency virus-1 infection and cytomegalovirus-associated esophagitis, who presented with an indolent clinical course associated with fever of an unknown origin, failure to thrive and weight loss.

Idiopathic biliary perforation in a 10-year-old boy

A 10-year-old boy of African origin with AIDS and Stage IV Hodgkin's lymphoma presented with a short history of abdominal distension and bile ascites shown to be due to a perforation of his common bile duct. This was treated initially by laparotomy, external peritoneal drainage and endoscopic biliary stenting although without success. He then underwent a laparotomy and biliary diversion (Roux-en-Y hepaticojejunostomy) with satisfactory resolution of his bile duct pathology. Although the co-morbid conditions are likely to be contributory factors, biliary perforation in either disease has not been reported before.

Gastrointestinal cytomegalovirus disease in patients with cancer: a two decade experience in a tertiary care cancer center

Although gastrointestinal cytomegalovirus disease (GI-CMVd) is not common in cancer patients, it is associated with high morbidity and mortality. Herein, we review our 2-decade experience with GI-CMVd in such patient population at The University of Texas M.D. Anderson Cancer Center. Forty-seven patients were identified. Thirty-four patients (72%) had an underlying haematological malignancy, and 18 patients (38%) developed GI-CMVd following hematopoietic stem cell transplantation (HSCT). Nine (25%) of the 36 cancer patients with data available had AIDS. Upper-GI tract involvement was more common in patients with haematological malignancies than in those with solid tumours (P=0.02). Patients with AIDS were more likely to have colonic involvement than were those without AIDS (67% vs. 15%, P=0.006), and patients without AIDS were more likely to have gastric involvement (59% vs. 11%, P=0.01). The CMV-attributable mortality rate was 42%. Independent predictors of death by multivariate analysis included disseminated CMV and AIDS (P<0.01). The presentation of GI-CMVd varies according to the type of cancer, and AIDS. GI-CMVd is associated with a high mortality among cancer patients, particularly those with disseminated CMV disease or AIDS.

Management of gastrointestinal disorders in children with HIV infection

A double scenario characterizes the epidemiology of HIV infection in children. In countries where highly active antiretroviral therapy (HAART) is available, the pattern of HIV infection is evolving into that of a chronic disease, for which control strictly depends on patients' adherence to treatment. In developing countries with no or limited access to HAART, AIDS is rapidly expanding and is loaded with a high fatality ratio, due to the combined effects of malnutrition and opportunistic infections. The digestive tract is a target of the disease in both settings. Opportunistic infections play a major role in children with severe immune impairment, with Cryptosporidium parvum being the leading agent of severe diarrhea. Several therapeutic approaches are effective in reducing fecal output, but the eradication of the parasite is rarely obtained. Other opportunistic infections may induce severe and protracted diarrhea, including atypical mycobacteria and cytomegalovirus. Diagnosis of diarrhea should be individually tailored based on presenting symptoms and risk factors. A stepwise approach is effective in limiting patient discomfort and minimizing the costs of investigations, starting with microbiologic investigation and proceeding with endoscopy and histology. Aggressive treatment of infectious diarrhea is required in severely immunocompromised children. However, antiretroviral therapy prevents the development of severe cryptosporidiosis. The liver and pancreas are also target organs in HIV infection, although functional failure is rare. The digestive-absorptive functions are impaired, with steatorrhea, nutrient malabsorption, and increased permeability occurring in 20-70% of children. Intestinal dysfunction contributes to growth failure and further immune derangement, leading to wasting, the terminal stage of AIDS. Nutritional management is crucial in HIV-infected children and is based on aggressive nutritional rehabilitation through enteral or parenteral routes and micronutrient supplementation.HIV may play a direct enteropathogenic role and is implicated in both diarrhea and intestinal dysfunction. This explains the efficacy of antiretroviral therapy in inducing remission of diarrhea and restoring intestinal function. Gastrointestinal side effects of antiretroviral drugs are increasingly observed; they are often mild and transient. Severe reactions are rare but require the withdrawal of drugs. In conclusion, severe enteric infections and intestinal dysfunction characterize the intestinal involvement of HIV infection. This is more common in, but not limited to, children who do not receive effective antiretroviral therapy. Diagnostic approaches include microbiologic and morphologic examinations and assessment of digestive processes, but immunologic and virologic data should be also carefully considered. Treatment is based upon specific anti-infectious drugs, antiretroviral therapy, and nutritional rehabilitation.

Gastrointestinal infections in immunocompromised hosts

PURPOSE OF REVIEW

Patients with immunocompromised states are increasing in the world not only because of HIV infection but also as a result of better therapies in solid organ transplantation, stem cell transplantation, and leukemia. All these patients are at similar risk of gastrointestinal infections, and the subsequent morbidity and mortality from these infections makes it important to recognize the net state of immunosuppression of each person infected.

RECENT FINDINGS

This review evaluates emerging pathogens, new diagnostic tools and guidelines, and the latest therapies published in the last 12 months in HIV and solid organ transplantation. The echinocandins provide a new therapy for Candida esophagitis, whereas Mycobacterium avium complex therapy may be discontinued with immune reconstitution in patients with HIV. The emergence of antimicrobial-resistant bacteria and viruses is a new threat to managing these infections, especially in poorer countries. Also, several community viruses such as adenovirus were shown to cause significant morbidity to immunocompromised patients. Lastly, the interaction among immunosuppressive medications, diarrhea, and rejection makes an important argument for evaluating patients for infection before adjusting medications.

SUMMARY

The immunocompromised host is rapidly increasing in the world, resulting in exposures to new pathogenic organisms that cause gastrointestinal infections. New diagnostic tests and better antimicrobial therapy are improving outcomes in patients with access to health care. Unfortunately, these challenges are increasing daily with the development of multidrug-resistant bacteria and viruses that do not respond to standard therapies. The most important factor in overcoming these infections is restoration of the immune system, either by using antiretroviral therapy or decreasing immunosuppression.