Cytomegalovirus infection in the gastrointestinal tract

An Unusual Case of an Immunocompetent Adult Diagnosed With Cytomegalovirus Colitis

Cytomegalovirus (CMV) infections are typically considered opportunistic in individuals with immunosuppressive conditions such as human immunodeficiency virus/acquired immunodeficiency syndrome, underlying malignancies, organ or bone marrow transplantation, and those receiving chemotherapeutics or steroids. Nevertheless, there is a significant increase in reported instances of CMV infections globally, suggesting that even individuals with a healthy immune system might experience these infections. In such cases, the primary symptoms are typically related to the gastrointestinal system, such as ulcerative colitis, pseudopolyps, tumors, and ischemic and hemorrhagic enterocolitis. We present a unique instance of severe CMV colitis in a patient with a fully functioning immune system. The diagnosis of CMV colitis was determined through the histological analysis of biopsy tissues acquired during colonoscopy.

[Infectious Gastric Diseases Other than Helicobacter]

In addition to Helicobacter pylori, the acute bacterial causes of infectious gastritis, include phlegmonous gastritis, gastric tuberculosis, and gastric syphilis. Bacterial gastritis often improves with appropriate broad-spectrum antibiotics, emphasizing the need for prompt diagnosis and treatment based on the clinical and endoscopic findings. Among viral gastritis, cytomegalovirus gastritis, primarily occurring in immunocompromised patients, necessitates antiviral intervention, while immunocompetent individuals typically achieve amelioration by administering proton pump inhibitors. In contrast, most gastric infections caused by the Epstein-Barr virus (EBV) are asymptomatic, but an EBV infection is a cause of stomach cancer. EBV-associated gastric cancer exhibits distinct clinical, pathological, genetic, and post-genetic mutation features, making it clinically significant. The colonization of Candida albicans in the stomach is uncommon, and typical antifungal treatment is unnecessary. Candida infections in gastric ulcers can be treated with anti-ulcer treatment alone. Lastly, anisakidosis in the stomach, which occurs when consuming raw seafood, can manifest in various clinical presentations and is typically treated through endoscopic removal of the nematode. This article aims to contribute to the rapid diagnosis and treatment of rare stomach infections beyond Helicobacter pylori in real clinical situations.

Infectious Disease Pathology of the Gastrointestinal Tract: Diagnosing the Challenging Cases

Infectious diseases of the GI tract mimic a variety of other GI diseases, including chronic idiopathic inflammatory bowel disease and ischemia. It can be challenging to identify pathogens in tissue sections as well, as many trainees are not exposed to infectious disease pathology other than in the context of microbiology. Our ability to diagnose infections in formalin fixed, paraffin embedded material has grown exponentially with the advent of new histochemical and immunohistochemical stains, as well as more options for molecular testing. Correlating these diagnostic techniques with morphology has led to increasing understanding of the histologic patterns that are associated with specific pathogens.

Cytomegalovirus and Herpes Simplex Virus Co-Infection: Recurrence in a Kidney Transplant Recipient

N/a.

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.

Atypical Viral Infections in Gastroenterology

Enteric viruses are commonly found obligate parasites in the gastrointestinal (GI) tract. These viruses usually follow a fecal-oral route of transmission and are characterized by their extraordinary stability as well as resistance in high-stress environments. Most of them cause similar symptoms including vomiting, diarrhea, and abdominal pain. In order to come in contract with mucosal surfaces, these viruses need to pass the three main lines of defense: mucus layer, innate immune defenses, and adaptive immune defenses. The following atypical gastrointestinal infections are discussed: SARS-CoV2, hantavirus, herpes simplex virus I, cytomegalovirus, and calicivirus. Dysbiosis represents any modification to the makeup of resident commensal communities from those found in healthy individuals and can cause a patient to become more susceptible to bacterial and viral infections. The interaction between bacteria, viruses, and host physiology is still not completely understood. However, with growing research on viral infections, dysbiosis, and new methods of detection, we are getting closer to understanding the nature of these viruses, their typical and atypical characteristics, long-term effects, and mechanisms of action in different organ systems.

Cytomegalovirus Disease in a Patient With Granulomatosis With Polyangiitis Who Also Has Splenic Necrosis

Cytomegalovirus infection, which can occur as a result of reactivation due to immunosuppressive treatment in patients with granulomatosis with polyangiitis, is a serious condition that should be kept in mind because of its fatal course. In this article, we report a 49-year-old male patient with a diagnosis of granulomatosis with polyangiitis who developed a life-threatening colonic ulcer due to cytomegalovirus colitis and a shrunken spleen with irregular contours that was detected on abdominal computed tomography. This is a rare case of cytomegalovirus disease in a patient with granulomatosis with polyangiitis and splenic necrosis.

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.

Spindle Cell Pseudotumor Mimicking Malignancy in an Immunocompetent Patient with a Left Ventricular Assist Device

Cytomegalovirus (CMV)-induced pseudotumors, or mass-like lesions in the colon, are a rare entity. We report a case of CMV-related spindle cell pseudotumor in an immunocompetent patient with a left ventricular assist device. This case highlights the importance of considering CMV-induced inflammatory pseudotumor when evaluating tumorous lesions in the colon, as well as the importance of appropriate diagnostic work-up, including proper biopsy technique and meticulous review of the pathology.

Inflammatory and infectious manifestations of immunodeficiency in the gastrointestinal tract

Immune compromise may result from genetic abnormalities, HIV/AIDS, or consequences of therapy for neoplastic and autoimmune diseases. Many immunocompromised patients develop severe gastrointestinal symptoms, particularly diarrhea, accompanied by non-specific or mild endoscopic abnormalities; mucosal biopsy with pathologic interpretation has a major role in the diagnosis and management of these patients. Immunocompromised individuals are at risk for all the diseases that affect those with a healthy immune system, but they are also prone to other illnesses that rarely affect immunocompetent patients. This review discusses the gastrointestinal manifestations of primary and acquired immunodeficiency, chemotherapy-related injury, and infections that show a predilection for immunocompromised patients. Key histologic features and relevant differential diagnoses are emphasized.

Routine Hematoxylin and Eosin Stain Is Specific for the Diagnosis of Cytomegalovirus Infection in Gastrointestinal Biopsy Specimens

BACKGROUND

Gastrointestinal cytomegalovirus (CMV) infection is a serious complication in immunocompromised patients; clinicians often expect expedited results for biopsy specimens. Our goal is to determine the accuracy of identification of CMV on hematoxylin and eosin (H&E) stain.

METHODS AND RESULTS

A total of 361 biopsy specimens from 273 patients with suspicion for CMV infection were retrieved. CMV was detected by immunohistochemistry (IHC) in 37 specimens acquired from 33 individual patients (average age = 54 years). Among the CMV-positive patients, 29 (88%) were reported to be immunosuppressed. Colon was the most common affected location. Of 37 CMV-positive specimens by IHC, 28 were positive by H&E (76%), 6 were negative (16%), and 3 were suspicious (8%). Of the 29 positive specimens on H&E, 28 were confirmed by IHC (97%) and 1 was indeterminate (3%). The sensitivity and specificity of H&E were 84% and 94%, respectively; the positive predictive value was 97%, and the negative predictive value was 93% ( P < .00001).

CONCLUSION

Our results show that a preliminary diagnosis of CMV infection, based on H&E stains, can be reported with high specificity and low risk for false-positive results. Suspicious cases should be deferred pending the result of IHC stains.

Overt Lower Gastrointestinal Bleeding and Pseudotumor: A Rare Presentation of Cytomegalovirus Infection

Cytomegalovirus (CMV) is a ubiquitous organism which can infect multiple organs of the body. In an immunocompromised patient, it can have a myriad of gastrointestinal manifestations. We report a case of recurrent hematochezia and concomitant pseudotumor in an AIDS (acquired immunodeficiency syndrome) patient attributable to CMV infection. A 62-year-old man with a history of AIDS, noncompliant with highly active antiretroviral therapy (HAART), presented with bright red blood per rectum. Index colonoscopy showed presence of multiple ulcers, colonic stenosis, and mass-like appearing lesion. Biopsy confirmed CMV infection and ruled out malignancy. Cessation of dual antiplatelet therapy and compliance with HAART lead to clinical cessation of bleeding and endoscopic healing of ulcers with complete resolution of colon mass on follow-up colonoscopy.

Ménétrier's Disease as a Gastrointestinal Manifestation of Active Cytomegalovirus Infection in a 22-Month-Old Boy: A Case Report with a Review of the Literature of Korean Pediatric Cases

Ménétrier’s disease (MD), which is characterized by hypertrophic gastric folds and foveolar cell hyperplasia, is the most common gastrointestinal (GI) cause of protein-losing enteropathy (PLE). The clinical course of MD in childhood differs from that in adults and has often been reported to be associated with cytomegalovirus (CMV) infection. We present a case of a previously healthy 22-month-old boy presenting with PLE, who was initially suspected to have an eosinophilic GI disorder. However, he was eventually confirmed, by detection of CMV DNA using polymerase chain reaction (PCR) with gastric tissue, to have MD associated with an active CMV infection. We suggest that endoscopic and pathological evaluation is necessary for the differential diagnosis of MD. In addition, CMV DNA detection using PCR analysis of biopsy tissue is recommended to confirm the etiologic agent of MD regardless of the patient’s age or immune status.

Cytomegalovirus and the Seemingly Immunocompetent Host: A Case of a Perforating Gastric Ulcer

Cytomegalovirus (CMV) infection of the gastrointestinal tract has a variety of presentations. We present a case of gastric perforation, which is a relatively infrequent presentation of CMV infection. If the cause of gastric perforation is not readily apparent, testing for CMV should be considered. If CMV workup is positive, an evaluation for immunocompromise is prudent as CMV infections are more common in immunocompromised individuals.

Cytomegalovirus appendicitis in an immunocompetent host

Cytomegalovirus (CMV) is a common viral pathogen. Asymptomatic infection or a mononucleosis syndrome are the most common manifestations in otherwise healthy individuals. End-organ disease is rare in immunocompetent individuals. Here, we describe a case of CMV appendicitis in a patient without an immune-compromising condition.

Cytomegalovirus-associated ulceration of gastric conduit after chemoradiotherapy following esophagectomy for cancer

A 64-year-old man underwent radical esophagectomy for cancer and simultaneous reconstruction using the gastric conduit through the posterior mediastinum. Two courses of adjuvant chemotherapy were performed. Twenty-eight months postoperatively, recurrence of the cancer was detected in the mediastinal lymph nodes, and he underwent concurrent chemoradiotherapy and boost chemotherapy. Endoscopy was then performed to investigate the cause of epigastralgia, and multiple ulcerations were found in the lesser curvature of the gastric conduit. Although a proton-pump inhibitor was orally administered, the ulceration was intractable. Re-examination of the original biopsy specimens and serological testing revealed positivity for cytomegalovirus. The ulcers began to heal after administration of foscarnet sodium. After the treatment, no signs of exacerbation associated with reinstitution of chemotherapy were observed.

Massive Alimentary Tract Bleeding due to Cytomegalovirus Infection in an Elderly Patient

In recent years, cytomegalovirus (CMV) has been recognized as an important common pathogen in immunocompromized patients. This is due to the increasing number of immunosuppressive medications, intensive cancer chemotherapy use, recurrent transplantations, progressively aging population, and the higher number of human immunodeficiency virus infections. Cytomegalovirus infection especially interests the gastrointestinal tract, anywhere, from the mouth to the anus. Namely, the most commonly affected area is the colon, followed by duodenum, stomach, esophagus and small intestine. The most frequent manifestations of CMV colitis are: diarrhea, fever, gastrointestinal bleeding and abdominal pain. We report here the case of an 82-year-old woman, who was treated for non-Hodgkin lymphoma; she was admitted to the emergency department for abdominal pain and diffuse arthralgia, following massive upper- and lower- gastrointestinal bleeding, due to duodenal and colonic ulcers related to CMV infection.

Acute appendicitis due to Cytomegalovirus in an apparently immunocompetent patient: a case report

Introduction

In healthy subjects, Cytomegalovirus infection can be asymptomatic or manifest as mononucleosis syndrome, but organ disease has also been reported. However, in immunocompromised patients this infection can lead to its most significant and severe disease and even mortality. When Cytomegalovirus causes a gastrointestinal tract infection, it more commonly manifests with luminal tract disease and is usually characterized by ulcerative lesions. Appendicitis is a rare manifestation, and has been reported mainly in human immunodeficiency virus-infected patients or patients with other causes of immunocompromise.

Case presentation

The authors report on a case of acute primary Cytomegalovirus infection complicated with acute appendicitis due to Cytomegalovirus in an apparently immunocompetent 24-year-old Caucasian man also suffering from primary sclerosing cholangitis and ulcerative colitis. Diagnosis was based on clinical manifestations, serology results, as well as microbiological and histological findings. Treatment consisted of surgery and anti-Cytomegalovirus therapy.

Conclusions

Cytomegalovirus should be included among the etiologic agents of acute appendicitis in patients with primary sclerosing cholangitis and ulcerative colitis. Currently, there are no definitive data regarding the frequency of Cytomegalovirus appendicitis and the role of anti-Cytomegalovirus treatment in human immunodeficiency virus-negative and apparently immunocompetent subjects.

Human immunodeficiency virus-related gastrointestinal pathology: a southern Africa perspective with review of the literature (part 1: infections)

CONTEXT

Human immunodeficiency virus infection is rife in sub-Saharan Africa and in southern Africa in particular. Despite the increasing availability of antiretroviral therapy in this region, opportunistic infections remain common and frequently involve the gastrointestinal tract.

OBJECTIVE

To review the histopathologic findings and distinguishing features of human immunodeficiency virus-associated gastrointestinal infections in southern Africa and relate those findings to the documented international literature.

DATA SOURCES

The available literature on this topic was reviewed and supplemented with personal experience in a private histopathology practice in South Africa.

CONCLUSIONS

In southern Africa, the range of gastrointestinal, opportunistic infectious pathology in human immunodeficiency virus afflicted patients is diverse and includes viral, bacterial, fungal, and parasitic infections. This infectious pathology is sometimes a manifestation of systemic disease. In profoundly immunocompromised patients, unusual histologic features, involvement of uncommon gastrointestinal tract sites, and more than one pathogen may be seen.

Cytomegalovirus infection of the colon presenting as a mass-like lesion

Cytomegalovirus (CMV) is responsible for the most common opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS). The colon is a common site for these infections in patients positive for human immunodeficiency virus. CMV rarely presents as an intraluminal inflammatory mass in the colon. Here we report the case of a CMV infection presenting as a mass-like lesion in an AIDS patient. The clinical diagnosis of CMV infection is largely based on the characteristic endoscopic appearance. Endoscopic procedures are encouraged early in the course of CMV infection in immunocompromised patients. CMV pseudotumors along with malignancy should be part of the endoscopic evaluation in patients with AIDS.

Pathology of diseases that cause upper gastrointestinal tract bleeding

Acute and chronic bleeding from the upper gastrointestinal tract is a common indication for endoscopy and hospitalization and is associated with significant morbidity and mortality. The causes of upper gastrointestinal bleeding are numerous and can result in both acute and chronic hemorrhage. The aim of this article is to examine the pathologic features of various diseases associated with upper gastrointestinal tract bleeding.

Cytomegalovirus infection of the upper gastrointestinal tract: a clinical and pathological study of 30 cases

OBJECTIVE

The study reviews the endoscopic and histological features of human cytomegalovirus (HCMV) infections of the upper gastrointestinal (UGI) tract.

MATERIALS AND METHODS

Clinical histories, endoscopic findings and bioptic specimens of 30 cases of HCMV infection of the UGI tract, diagnosed in a University Hospital in a 10-year period, were reviewed. In all cases, viral inclusion bodies were detected in routine histopathological sections and the diagnosis was confirmed with immunohistochemistry.

RESULTS

Six patients were HIV+, whereas four had received organ transplantations, one was affected by common variable immunodeficiency and four had a recent history of malignancy. No other pathologic condition was evidenced in the remaining 15 cases. Mucosal alterations were endoscopically observed in the stomach (19 cases), esophagus (9), cardias (6) and duodenum (1), and multiple organs being synchronously affected in five patients (3 HIV+, 2 with history of malignancy). The antropyloric area was the most frequently affected site. Single ulcers were detected in 11 cases and multiple ulcers in 8, whereas mucosal thickenings (in the form of localized thickenings, polyps or rugal hypertrophy) were present in 13 patients. Thickenings of the mucosa were detected only in the stomach. At histology, necrotic material and granulation tissue were associated with moderate or marked lympho-plasmacytic infiltrate and foveolar hyperplasia in ulcerative lesions, whereas lesions labeled as mucosal thickenings showed mild or moderate chronic inflammatory infiltrate and foveolar hyperplasia.

CONCLUSIONS

Endoscopic manifestations of UGI tract involvement in HCMV infection are not specific, varying from erythematous mucosa to ulcers to mucosal thickenings.

Infectious causes of appendicitis

The pathologic spectrum of the inflamed appendix encompasses a wide range of infectious entities, some with specific histologic findings, and others with nonspecific findings that may require an extensive diagnostic evaluation. The appendix is exclusively involved in some of these disorders, and in others may be involved through extension from other areas of the gastrointestinal tract. This review discusses the pathologic features of bacterial, viral, fungal, and parasitic infections affecting the appendix, including adenovirus; cytomegalovirus; Yersinia, Actinomyces, Mycobacterium, or Histoplasma species; Enterobius vermicularis; schistosomiasis; and Strongyloides stercoralis. Pertinent ancillary diagnostic techniques and the clinical context and significance of the various infections are also discussed.

Cytomegalovirus gastritis

Cytomegalovirus (CMV) has been increasingly recognized as an important common pathogen in an immunocompromised state. The colon and stomach are the most common sites of its gastrointestinal infection. Symptoms of CMV gastritis are usually nonspecific and include epigastric pain, fever, nausea and bleeding. Endoscopic features are quite variable and include macroscopically normal mucosa, diffuse erythema, nodules, pseudotumors, erosions and ulcers. The bioptic detection of intranuclear inclusions is the hallmark of CMV infection. Most gastrointestinal CMV infection responds well to ganciclovir. We present endoscopic and histopathological features of CMV gastritis in a 71 year old woman receiving long-term prednisolone for pemphigus vulgaris.

Cecal vanishing tumor associated with cytomegalovirus infection in an immunocompetent elderly adult

Gastrointestinal involvement in cytomegalovirus (CMV) infection is well documented among immunocompromised patients and is also observed in immunocompetent individuals. The presentation of this infection can sometimes mimic those of other diseases, thus making accurate diagnosis difficult. We herein report a rare case of an immunocompetent elderly adult with gastrointestinal CMV infection that presented as a vanishing tumor at the cecum. A 76-year old man initially presented with lower abdominal pain. Colonoscopy revealed a tumorous lesion with irregular ulceration observed at the ileocecal valve. Histological findings of a biopsy specimen revealed intranuclear inclusions which were positive for CMV on immunohistochemical staining. However, this tumorous lesion disappeared within 7 wk from the initial hospital visit without any further treatment. Inflammatory pseudotumors associated with CMV infection should be considered as a differential diagnosis of tumorous lesions in the colon, even in immunocompetent adults.

Infectious Diseases of the Lower Gastrointestinal Tract

Gastrointestinal (GI) infections are a major cause of morbidity and mortality worldwide. Although infectious organisms are often recovered by microbiological methods, surgical pathologists play an invaluable role in diagnosis. The lower GI tract, including the appendix, large bowel, and anus, harbors a wide variety of pathogens. Some infections are part of disseminated disease, whereas others produce clinicopathologic scenarios that are specific to the lower GI tract. This review focuses on selected infectious disorders of the lower GI tract that may be encountered by the general surgical pathologist, including viral, bacterial, fungal, and parasitic organisms, and including infections caused by food- and water-borne pathogens. Diagnostic gross and histologic features are discussed, as well as useful clinical features and ancillary diagnostic techniques. Pertinent differential diagnoses are also emphasized, including other inflammatory conditions of the gut (such as ischemia or idiopathic inflammatory bowel disease) that can be mimicked by lower GI infections.

[Cytomegalovirus induced gastric ulcer as a principal manifestation in the initial stage of hodgkins disease]

Cytomegalovirus (CMV) is an important cause of opportunistic infection in immunocompromised patients. CMV infection occurs as a result of the cell-mediated immunity change in lymphoma patients. Although CMV can cause ulceration anywhere in the gastrointestinal (GI) tract in immunocompromised patients, only a few case reports about CMV GI infection in malignant lymphoma have been documented in literature. Furthermore, it was rare that CMV gastric ulcer with massive bleeding presented as an initial manifestation in a patient who has been not diagnosed lymphoma. We report a case of CMV induced gastric ulcer as an initial manifestation in patient with Hodgkins disease.

Unusual presentation of cytomegalovirus enteritis after liver and kidney transplantation

Cytomegalovirus (CMV) is a cause of significant morbidity and mortality in solid organ transplant recipients. Gastrointestinal (GI) tract infection by CMV in this population can cause symptomatic disease, which typically manifests as fever, abdominal pain, nausea, and bloody diarrhea. Erosive lesions of the GI mucosa are often evident on endoscopic exam. We report an unusual presentation of CMV enteritis in a kidney and liver transplant recipient with the development of acute onset voluminous watery diarrhea in the absence of other typical symptoms and subsequent progression to hypovolemic shock and acute renal failure. This case emphasizes the atypical presentations of common opportunistic infections that may occur in immunosuppressed hosts.

Immunohistochemically proven cytomegalovirus end-organ disease in solid organ transplant patients: clinical features and usefulness of conventional diagnostic tests

We studied the main clinical features, outcome, and laboratory parameters in a group of solid organ transplant (SOT) patients with immunohistochemically proven cytomegalovirus (CMV) disease. Confirmed CMV cases were obtained through databases. Demographics, clinical data, transplantation type, immunosuppressive regimens, donor and recipient CMV serostatus, therapy, outcome and laboratory results, pp65 antigenemia, and qualitative polymerase chain reaction (PCR) for CMV were analyzed. From 1995 to 2004, 31 cases with complete medical records were identified. Disease appeared between 24 and 2538 days after transplantation but most cases presented in the first 100 days. Gastrointestinal CMV disease was the most frequent form (71%), while thrombocytopenia was present in 50% of cases, and leukopenia was less common (35.5%). CMV pp65 antigenemia was positive in 58% of patients, but its sensitivity increased to 71% if performed during the first 6 months. A qualitative CMV PCR technique gave similar results during this period (71.4%). Most patients were treated with intravenous ganciclovir (n=25; 80.6%). In 4 cases (19.4%), use of foscarnet alone or a sequential regimen with ganciclovir-foscarnet was deemed necessary. Surgical procedures were necessary in 5 patients (16%). The death rate reached 13%. CMV end-organ disease can be a life-threatening infection in SOT patients. Gastrointestinal disease was the most frequent end-organ disease. CMV antigen detection is best suited for the early period after transplantation.

Human cytomegalovirus infection of the gastrointestinal tract in apparently immunocompetent patients

Human cytomegalovirus (HCMV) infection is usually reported in immunocompromised patients. This study reports 11 cases of HCMV infection of the gastrointestinal (GI) tract diagnosed in apparently immunocompetent hosts. The median age of the patients studied was 76 years, and the major presenting symptoms were diarrhea, epigastric pain, and abdominal discomfort. The large intestine was involved in 6 cases, the stomach in 4 cases, and the lower esophagus in 1 case. Endoscopy revealed ulcers or hypertrophic folds in the GI tract and single ulcers or erosions in the colon and rectum. Light microscopy showed chronic inflammatory infiltrate in the lamina propria in all cases. The diagnosis of HCMV infection was based on the histological and immunohistochemical identification of HCMV inclusion bodies in different cell types, including epithelial, endothelial, stromal, and smooth muscle cells. Both "classical" inclusions, characterized by an "owl's eye" appearance, and atypical inclusions were found. For all patients, no apparent causes of immunodeficiency were detected at the time of diagnosis of HCMV infection. At follow-up, however, 4 patients were found to harbor a malignant tumor (ie, pancreas, lung, Vater's papilla, and extrahepatic bile duct) at an interval of 2 to 5 months after the diagnosis of HCMV infection. Especially in elderly patients, HCMV infection of the GI tract might be an early clue to the presence of immunologic defects induced by an underlying neoplasia.

Pseudoneoplastic appearance of cytomegalovirus-associated colitis in nonimmunocompromised patients: report of 2 cases

Two cases of human cytomegalovirus (HCMV) colitis with pseudoneoplastic appearance are described. Patients presented with abdominal pain, fever, and diarrhea. Colonoscopy revealed a stenosing lesion in one patient and a broad-based, vegetant mass in the other patient, and histopathological examination of colectomy specimens revealed exuberant inflammatory masses with infiltration of mononuclear cells and ulcers with granulation tissue. Typical intranuclear HCMV inclusions were numerous. Peculiar to both patients was the lack of any apparent causes of immunodeficiency, such as human immunodeficiency virus infection or previous organ transplantation.

Congenital cytomegalovirus infection after recurrent infection: case reports and review of the literature

Cytomegalovirus (CMV) is one of the most common causes of congenital infections in developed countries with reported incidences varying between 0.15% and 2.0%. The effects of congenital CMV infection may vary from a congenital syndrome to an asymptomatic course. Infants that are asymptomatic at birth may still present handicaps at a later age. It is generally accepted that symptoms of congenitally infected children are more severe after primary infection than after recurrent infection. In this article, we present two case reports which demonstrate that the outcome of recurrent maternal CMV infection may be severe. In the first case, early pregnancy serology showed positive IgG and IgM, but negative IgA, whereas at the time of diagnosed fetal death, 5 weeks later, there was only positive IgG. The second case showed positive IgG and negative IgM and IgA both in early pregnancy and after delivery. Since in both cases CMV was isolated from several organs, these findings are compatible with recurrent rather than primary CMV infection. In the reported patients, fetal death and necrotising enterocolitis occurred after a congenital CMV infection, with mothers having pre-existing immunity to CMV. In conclusion, these case reports and review of the literature emphasise that the outcome of recurrent maternal CMV infection may be severe and that congenital CMV infection should be considered in cases of pregnancy loss and necrotising enterocolitis with recurrent maternal CMV infection.

Detection of cytomegalovirus in upper gastrointestinal biopsies from heart transplant recipients: comparison of light microscopy, immunocytochemistry, in situ hybridisation, and nested PCR

AIM

To establish the diagnostic value of in situ hybridisation and the nested polymerase chain reaction (PCR) in detecting clinically relevant cytomegalovirus (CMV) infection in upper gastrointestinal biopsies from heart transplant patients.

METHODS

Test sensitivity and specificity for detection of CMV early gene RNA by in situ hybridisation and CMV intermediate early gene by PCR were established and then compared with haematoxylin and eosin (H&E) and immunocytochemical detection of CMV in order to establish the best pathological diagnostic approach. All investigations were carried out on formalin fixed, paraffin embedded tissue.

RESULTS

Nested PCR had the highest test sensitivity, followed by in situ hybridisation and immunocytochemistry with the same sensitivity; H&E had the lowest. H&E and immunocytochemistry were the most specific but both had a significant false negative rate which was less of a problem with PCR. However, PCR gave no other diagnostic information, and in situ hybridisation was no better than immunocytochemistry. Both in situ hybridisation and PCR were technically complex and more expensive.

CONCLUSIONS

H&E and immunocytochemistry represent the best initial screen for CMV and other diseases in upper gastrointestinal biopsies from heart transplant patients. If H&E and immunocytochemistry were negative, nested PCR could significantly increase the diagnostic yield of clinically relevant CMV infection. In situ hybridisation appeared to have no advantages and some drawbacks compared with immunocytochemistry and PCR.

Ileal perforation caused by congenital or perinatal cytomegalovirus infection

Enteritis developed in a 42-day-old female infant, and during hospitalization ileal perforation occurred unexpectedly. Serologic data, urinary viral culture, and pathologic studies of the resected ileal segment all suggested cytomegalovirus infection. Gastrointestinal involvement in congenital or perinatal infection with this virus may be relatively more common than previously recognized.