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Fernández S, Grafia I, Peyrony O, Canet E, Vigneron C, Monet C, Issa N, Decavele M, Moreau AS, Lautrette A, Lacave G, Morel G, Cadoz C, Argaud L, Statlender L, Azem K, Quenot JP, Lesieur O, Fernández J, Farrero M, Marcos MÁ, Lemiale V, Castro P, Azoulay É. Clinical characteristics and outcomes of immunocompromised critically ill patients with cytomegalovirus end-organ disease: a multicenter retrospective cohort study. Crit Care 2024; 28:243. [PMID: 39014504 PMCID: PMC11251242 DOI: 10.1186/s13054-024-05029-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 07/08/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection in patients with cellular immune deficiencies is associated with significant morbidity and mortality. However, data on CMV end-organ disease (CMV-EOD) in critically ill, immunocompromised patients are scarce. Our objective here was to describe the clinical characteristics and outcomes of CMV-EOD in this population. METHODS We conducted a multicenter, international, retrospective, observational study in adults who had CMV-EOD and were admitted to any of 18 intensive care units (ICUs) in France, Israel, and Spain in January 2010-December 2021. Patients with AIDS were excluded. We collected the clinical characteristics and outcomes of each patient. Survivors and non-survivors were compared, and multivariate analysis was performed to identify risk factors for hospital mortality. RESULTS We studied 185 patients, including 80 (43.2%) with hematologic malignancies, 55 (29.7%) with solid organ transplantation, 31 (16.8%) on immunosuppressants, 16 (8.6%) with solid malignancies, and 3 (1.6%) with primary immunodeficiencies. The most common CMV-EOD was pneumonia (n = 115, [62.2%] including 55 [47.8%] with a respiratory co-pathogen), followed by CMV gastrointestinal disease (n = 64 [34.6%]). More than one organ was involved in 16 (8.8%) patients. Histopathological evidence was obtained for 10/115 (8.7%) patients with pneumonia and 43/64 (67.2%) with GI disease. Other opportunistic infections were diagnosed in 69 (37.3%) patients. Hospital mortality was 61.4% overall and was significantly higher in the group with hematologic malignancies (75% vs. 51%, P = 0.001). Factors independently associated with higher hospital mortality were hematologic malignancy with active graft-versus-host disease (OR 5.02; 95% CI 1.15-27.30), CMV pneumonia (OR 2.57; 95% CI 1.13-6.03), lymphocytes < 0.30 × 109/L at diagnosis of CMV-EOD (OR 2.40; 95% CI 1.05-5.69), worse SOFA score at ICU admission (OR 1.18; 95% CI 1.04-1.35), and older age (OR 1.04; 95% CI 1.01-1.07). CONCLUSIONS Mortality was high in critically ill, immunocompromised patients with CMV-EOD and varied considerably with the cause of immunodeficiency and organ involved by CMV. Three of the four independent risk factors identified here are also known to be associated with higher mortality in the absence of CMV-EOD. CMV pneumonia was rarely proven by histopathology and was the most severe CMV-EOD.
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Affiliation(s)
- Sara Fernández
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain.
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
| | - Ignacio Grafia
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain
- Department of Medical Oncology, IDIBAPS, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, CHU de Nantes, Université de Nantes, Nantes, France
| | - Clara Vigneron
- Médecine Intensive et Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Clément Monet
- Anesthesia and Critical Care Department, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS, Montpellier, France
| | - Nahéma Issa
- Medical Intensive Care Unit, Hôpital Saint André, CHU Bordeaux, Bordeaux, France
| | - Maxens Decavele
- Medical Intensive Care Unit (Department R3S), Pitié-Salpêtrière University Hospital, Sorbonne University Hospitals, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- INSERM Research Unit UMRS1158, Experimental and Clinical Respiratory Neurophysiology, Sorbonne University, Paris, France
| | | | - Alexandre Lautrette
- Medical Intensive Care Unit, Jean Perrin Oncology Institut and Montpied Teaching Hospital, Clermont-Ferrand, France
| | - Guillaume Lacave
- Medical-Surgical Intensive Care Unit, Versailles Hospital Center, Le Chesnay, France
| | - Guillaume Morel
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | - Cyril Cadoz
- Réanimation Polyvalente, CHR Metz-Thionville Hôpital de Mercy, Metz, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Liran Statlender
- General Intensive Care Unit, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karam Azem
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Anesthesiology Department, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Jean-Pierre Quenot
- Deparment of Intensive Care, Burgundy University Hospital, Dijon, France
| | - Olivier Lesieur
- Intensive Care Unit, La Rochelle General Hospital, La Rochelle, France
| | - Javier Fernández
- Liver Intensive Care Unit, Hospital Clinic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- EF-Clif, Barcelona, Spain
| | - Marta Farrero
- Heart Failure Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Mª Ángeles Marcos
- Microbiology Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Virgine Lemiale
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Élie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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Song S, Guo W, Zou S, Zhou F, Luo M, Chen L, Liang K. Life-threatening gastrointestinal bleeding caused by cytomegalovirus-induced duodenal ulcer in a patient with AIDS: A case report. Heliyon 2024; 10:e30112. [PMID: 38737287 PMCID: PMC11087948 DOI: 10.1016/j.heliyon.2024.e30112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/19/2024] [Accepted: 04/19/2024] [Indexed: 05/14/2024] Open
Abstract
Background The reasons for gastrointestinal bleeding among patients with acquired immune deficiency syndrome (AIDS) were complex. Here we present an unusual case of life-threatening gastrointestinal bleeding caused by a cytomegalovirus-induced duodenal ulcer in an AIDS patient. Case presentation A 31-year-old male with AIDS was admitted on July 18, 2023, complaining of abdominal pain for 38 days and intermittent hematochezia for 12 days. During his hospitalization, gastrointestinal endoscopy attributed gastrointestinal bleeding to a giant duodenal ulcer. Furthermore, cytomegalovirus(CMV) infection was confirmed as the reason for the ulcer through metagenomic next-generation sequencing (mNGs), hematoxylin-eosin(HE) staining, and immunohistochemistry (IHC) staining for the biopsy tissue. The patient's gastrointestinal bleeding was stopped by interventional embolization. Following a 4-week course of anti-CMV treatment, the giant duodenal ulcer was cured. Conclusions For AIDS patients with gastrointestinal bleeding, the CMV-induced gastrointestinal ulcer should be considered. Comprehensive mothods (mNGs, HE staining and IHC staining for biopsy tissue) were benefit for confirmed diagnosis. Beside anti-CMV treatment, the interventional embolization is a choice for hemostasis.
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Affiliation(s)
- Shihui Song
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
- Center for AIDS Research, Wuhan University, Wuhan, Hubei Province, China
| | - Wei Guo
- Department of Pathology, Wuhan University Taikang Medical School, School of Basic Medical Sciences, Wuhan, Hubei Province, China
- Pathology Department, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Shi Zou
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
- Center for AIDS Research, Wuhan University, Wuhan, Hubei Province, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, Hubei Province, China
| | - Feng Zhou
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Hubei Clinical Center and Key Laboratory for Intestinal and Colorectal Diseases, Wuhan, Hubei Province,China
| | - Mingqi Luo
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Li Chen
- Infectious Immunology Department, Wuhan Jinyintan Hospital, Tongji Medical College of Huazhong University of Science and Technology,Wuhan, Hubei Province, China
| | - Ke Liang
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
- Center for AIDS Research, Wuhan University, Wuhan, Hubei Province, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, Hubei Province, China
- Department of Nosocomial Infection Management, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
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Sauqué Pintos G, Antolí Gil A, Rocamora Blanch G, Avila Espinoza R, Taco Sánchez R, Sabé Fernández N, Solanich Moreno X. Severe Gastrointestinal Cytomegalovirus Infection in a Patient Diagnosed with Late Onset Combined Immunodeficiency. Eur J Case Rep Intern Med 2024; 11:004390. [PMID: 38846656 PMCID: PMC11152241 DOI: 10.12890/2024_004390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 06/09/2024] Open
Abstract
Late onset combined immunodeficiency (LOCID) is a rare variant of common variable immunodeficiency (CVID), typically affecting adult patients who present with opportunistic infections (OI) and/or low CD4+ T lymphocytes. Diagnostic delay is common due to the rareness of this entity, increasing morbidity and mortality. We report on a 66-year-old male who developed a severe gastrointestinal cytomegalovirus (CMV) infection, refractory to antiviral treatment and anti-cytomegalovirus specific human immunoglobulin administration, with a fatal outcome due to an undiagnosed LOCID. LEARNING POINTS Infections in patients with primary immunodeficiencies (PIDs) could be more severe and life-threatening than in immunocompetent hosts.PIDs are not exclusive to paediatric patients; diagnostic delay is common, and they should also be suspected in adulthood.Diagnostic delay in PID patients is associated with more morbidity and mortality.
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Affiliation(s)
- Georgina Sauqué Pintos
- Department of Internal Medicine, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Arnau Antolí Gil
- Department of Internal Medicine, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
- Adult Primary Immunodeficiency Unit, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
| | - Gemma Rocamora Blanch
- Department of Internal Medicine, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
- Adult Primary Immunodeficiency Unit, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
| | - Renzo Avila Espinoza
- Deparment of Intensive Care Medicine, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Rosario Taco Sánchez
- Department of Anatomical Pathology, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Núria Sabé Fernández
- Adult Primary Immunodeficiency Unit, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
- Deparment of Infectious Diseases, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Solanich Moreno
- Department of Internal Medicine, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
- Adult Primary Immunodeficiency Unit, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
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4
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Reis Schneider GA, Bogoni G, Castanheira NF, Lucas Júnior RM, Vidal JE. AIDS-related gastrointestinal cytomegalovirus end-organ disease: A retrospective cohort study at a tertiary center in São Paulo, Brazil. Int J STD AIDS 2024; 35:365-373. [PMID: 38158813 DOI: 10.1177/09564624231222962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
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.
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Affiliation(s)
| | - Giuliane Bogoni
- Departamento de Infectologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil
| | | | | | - José Ernesto Vidal
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Investigação Médica (LIM 49) da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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5
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Yeh PJ, Wu RC, Tsou YK, Chen CM, Chiu CT, Chen CC, Lai MW, Pan YB, Le PH. Comparative Analysis of Cytomegalovirus Gastrointestinal Disease in Immunocompetent and Immunocompromised Patients. Viruses 2024; 16:452. [PMID: 38543817 PMCID: PMC10974964 DOI: 10.3390/v16030452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) gastrointestinal (GI) diseases impact both immunocompromised and immunocompetent individuals, yet comprehensive studies highlighting the differences between these groups are lacking. METHODS In this retrospective study (January 2000 to July 2022) of 401 patients with confirmed CMV GI diseases, we categorized them based on immunological status and compared manifestations, treatments, outcomes, and prognostic factors. RESULTS The immunocompromised patients (n = 193) showed older age, severe illnesses, and higher comorbidity rates. GI bleeding, the predominant manifestation, occurred more in the immunocompetent group (92.6% vs. 63.6%, p = 0.009). Despite longer antiviral therapy, the immunocompromised patients had higher in-hospital (32.2% vs. 18.9%, p = 0.034) and overall mortality rates (91.1% vs. 43.4%, p < 0.001). The independent factors influencing in-hospital mortality in the immunocompromised patients included GI bleeding (OR 5.782, 95% CI 1.257-26.599, p = 0.024) and antiviral therapy ≥ 14 days (OR 0.232, 95% CI 0.059-0.911, p = 0.036). In the immunocompetent patients, age (OR 1.08, 95% CI 1.006-1.159, p = 0.032), GI bleeding (OR 10.036, 95% CI 1.183-85.133, p = 0.035), and time to diagnosis (OR 1.029, 95% CI 1.004-1.055, p = 0.021) were significant prognostic factors, with the age and diagnosis time cut-offs for survival being 70 years and 31.5 days, respectively. CONCLUSIONS GI bleeding is the most common manifestation and prognostic factor in both groups. Early diagnosis and effective antiviral therapy can significantly reduce in-hospital mortality.
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Affiliation(s)
- Pai-Jui Yeh
- Department of Pediatric Gastroenterology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (P.-J.Y.); (C.-C.C.); (M.-W.L.)
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Ren-Chin Wu
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Department of Anatomic Pathology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yung-Kuan Tsou
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
| | - Chien-Ming Chen
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Department of Medical Imaging and Interventions, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Cheng-Tang Chiu
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan 333, Taiwan
| | - Chien-Chang Chen
- Department of Pediatric Gastroenterology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (P.-J.Y.); (C.-C.C.); (M.-W.L.)
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ming-Wei Lai
- Department of Pediatric Gastroenterology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (P.-J.Y.); (C.-C.C.); (M.-W.L.)
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
| | - Yu-Bin Pan
- Biostatistical Section, Clinical Trial Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
| | - Puo-Hsien Le
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan 333, Taiwan
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6
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Yeh PJ, Wu RC, Chen CL, Chiu CT, Lai MW, Chen CC, Chiu CH, Pan YB, Lin WR, Le PH. Cytomegalovirus Diseases of the Gastrointestinal Tract in Immunocompetent Patients: A Narrative Review. Viruses 2024; 16:346. [PMID: 38543712 PMCID: PMC10975113 DOI: 10.3390/v16030346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/17/2024] [Accepted: 02/22/2024] [Indexed: 05/23/2024] Open
Abstract
Cytomegalovirus (CMV) is a potential pathogen that causes gastrointestinal (GI) tract diseases regardless of host immunity. In contrast to immunocompromised individuals, immunocompetent patients lack a comprehensive overview of the gastrointestinal manifestations. This study aims to provide a comprehensive summary of the current evidence regarding presentations, diagnostics, management, risk assessment, and outcomes in immunocompetent patients with CMV GI disease. A thorough literature search of English publications up to April 2022 was conducted across electronic databases to identify relevant articles, with eligible case series selected for detailed analysis. The majority of immunocompetent patients affected by CMV GI disease are typically elderly, critically ill, or burdened with comorbidities that compromise immunity. Clinical presentations range from subtle symptoms to severe surgical conditions, including instances of mortality. Specific clinical presentations, blood test results, or endoscopic features are lacking, necessitating reliance on histopathological tests such as immunohistochemistry staining for diagnosis. While antiviral therapy may offer benefits in improving outcomes, careful individual assessment is warranted due to diverse comorbidities and potential side effects. Mortality rates vary considerably based on underlying medical conditions and therapeutic approaches. It is imperative for clinicians to maintain vigilance for CMV GI disease among high-risk groups, despite their baseline immunocompetence, in order to enhance clinical outcomes.
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Affiliation(s)
- Pai-Jui Yeh
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (P.-J.Y.); (M.-W.L.); (C.-C.C.)
- Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
| | - Ren-Chin Wu
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
- Department of Pathology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
| | - Chyi-Liang Chen
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (C.-L.C.); (C.-H.C.)
| | - Cheng-Tang Chiu
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
- Department of Pathology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan 333, Taiwan
| | - Ming-Wei Lai
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (P.-J.Y.); (M.-W.L.); (C.-C.C.)
- Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
| | - Chien-Chang Chen
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (P.-J.Y.); (M.-W.L.); (C.-C.C.)
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
| | - Cheng-Hsun Chiu
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (C.-L.C.); (C.-H.C.)
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yu-Bin Pan
- Biostatistical Section, Clinical Trial Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
| | - Puo-Hsien Le
- Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (R.-C.W.); (C.-T.C.)
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan 333, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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7
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Zais IE, Sirotti A, Iesari S, Campioli E, Costantino A, Delbue S, Collini A, Guarneri A, Ambrogi F, Cacciola R, Ferraresso M, Favi E. Human cytomegalovirus-related gastrointestinal disease after kidney transplantation: A systematic review. Clin Transplant 2024; 38:e15218. [PMID: 38063324 DOI: 10.1111/ctr.15218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/14/2023] [Accepted: 11/27/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Human-cytomegalovirus (hCMV) infection involving the gastrointestinal tract represents a leading cause of morbidity and mortality among kidney transplant (KT) recipients (KTRs). Signs and symptoms of the disease are extremely variable. Prompt anti-viral therapy administration and immunosuppression modification are key factors for optimizing management. However, complex work-up strategies are generally required to confirm the preliminary diagnosis. Unfortunately, solid evidence and guidelines on this specific topic are not available. We consequently aimed to summarize current knowledge on post-KT hCMV-related gastrointestinal disease (hCMV-GID). METHODS We conducted a systematic review (PROSPERO ID: CRD42023399363) about hCMV-GID in KTRs. RESULTS Our systematic review includes 52 case-reports and ten case-series, published between 1985 and 2022, collectively reporting 311 cases. The most frequently reported signs and symptoms of hCMV-GID were abdominal pain, diarrhea, epigastric pain, vomiting, fever, and GI bleeding. Esophagogastroduodenoscopy and colonoscopy were the primary diagnostic techniques. In most cases, the preliminary diagnosis was confirmed by histology. Information on anti-viral prophylaxis were extremely limited as much as data on induction or maintenance immunosuppression. Treatment included ganciclovir and/or valganciclovir administration. Immunosuppression modification mainly consisted of mycophenolate mofetil or calcineurin inhibitor minimization and withdrawal. In total, 21 deaths were recorded. Renal allograft-related outcomes were described for 26 patients only. Specifically, reported events were acute kidney injury (n = 17), transplant failure (n = 5), allograft rejection (n = 4), and irreversible allograft dysfunction (n = 3). CONCLUSIONS The development of local and national registries is strongly recommended to improve our understanding of hCMV-GID. Future clinical guidelines should consider the implementation of dedicated diagnostic and treatment strategies.
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Affiliation(s)
| | - Alessandro Sirotti
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Samuele Iesari
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edoardo Campioli
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Costantino
- Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Serena Delbue
- Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milan, Italy
| | - Andrea Collini
- Renal Transplant Unit, Siena University Hospital, Siena, Italy
| | - Andrea Guarneri
- Department of Clinical Sciences and Community Health (DISCCO), Università degli Studi di Milano, Milan, Italy
| | - Federico Ambrogi
- Department of Clinical Sciences and Community Health (DISCCO), Università degli Studi di Milano, Milan, Italy
| | - Roberto Cacciola
- Dipartimento di Scienze Chirurgiche, Università di Roma Tor Vergata, Rome, Italy
| | - Mariano Ferraresso
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health (DISCCO), Università degli Studi di Milano, Milan, Italy
| | - Evaldo Favi
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health (DISCCO), Università degli Studi di Milano, Milan, Italy
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8
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Kim JH, Kim HS, Jeong HW. Coexisting cytomegalovirus colitis in an immunocompetent patient with Clostridioides difficile colitis: A case report. World J Clin Cases 2023; 11:2343-2348. [PMID: 37122504 PMCID: PMC10131014 DOI: 10.12998/wjcc.v11.i10.2343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/12/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Clostridioides difficile (C. difficile) colitis is one of the most common infections in hospitalized patients, characterized by fever and diarrhea. It usually improves after appropriate antibiotic treatment; if not, comorbidities should be considered. Cytomegalovirus (CMV) colitis is a possible co-existing diagnosis in patients with C. difficile infection with poor treatment response. However, compared with immunocompromised patients, CMV colitis in immunocompetent patients is not well studied.
CASE SUMMARY We present an unusual case of co-existing CMV colitis in an immunocompetent patient with C. difficile infection. An 80-year-old female patient was referred to the infectious disease department due to diarrhea, abdominal discomfort, and fever for 1 wk during her hospitalization for surgery. C. difficile toxin B polymerase chain reaction on stool samples was positive. After C. difficile infection was diagnosed, oral vancomycin treatment was administered. Her symptoms including diarrhea, fever and abdominal discomfort improved for ten days. Unfortunately, the symptoms worsened again with bloody diarrhea and fever. Therefore, a sigmoidoscopy was performed for evaluation, showing a longitudinal ulcer on the sigmoid colon. Endoscopic biopsy confirmed CMV colitis, and the clinical symptoms improved after using ganciclovir.
CONCLUSION Co-existing CMV colitis should be considered in patients with aggravated C. difficile infection on appropriate treatment, even in immunocompetent hosts.
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Affiliation(s)
- Jun Hyoung Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju 28644, Chungbuk, South Korea
| | - Hee-Sung Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju 28644, Chungbuk, South Korea
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju 28644, Chungbuk, South Korea
| | - Hye Won Jeong
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju 28644, Chungbuk, South Korea
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju 28644, Chungbuk, South Korea
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9
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Lin SH, Wu KT, Wang CC, Liu TT, Eng HL, Chiu KW. Immunohistochemistry Staining-Proven Cytomegalovirus Colitis in Living Donor Liver Transplantation. Viruses 2022; 15:115. [PMID: 36680155 PMCID: PMC9862431 DOI: 10.3390/v15010115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
Background and Aims: Cytomegalovirus (CMV) infection is a common occurrence in liver transplantation (LT) even in an era of preventive strategies. However, the diagnosis of CMV colitis remains challenging. This study aimed to focus on the clinical significance of endoscopic biopsy-proven CMV colitis in patients following living donor liver transplantation (LDLT). Methods: From January 2007 to December 2021, a total of 55 CMV colitis cases were retrospectively enrolled and divided into a non-LDLT group in 53 and an LDLT group in 2 cases. Clinical demographics, diagnostic measurement, histopathology, and anti-viral therapy were investigated. Results: There were 1630 cases undergoing LDLT in the period 2007-2021, with only 2 recipients being confirmed to have CMV colitis in 2021 (2/114, 1-year incidence: 1.75%). Comparisons between the 53 non-LDLT cases and 2 LDLT cases are as follows: Serum anti-CMV immunoglobulin M (IgM) was shown to be positive (n = 3, 5.5% vs. n = 0, p = 1.0) and negative (n = 20, 37.7% vs. n = 2, 100%, p = 0.16); anti-CMV immunoglobulin G (IgG) was positive (n = 19, 35.8% vs. n = 2, 100%, p = 0.14) and none were negative; CMV DNAemia was shown to be detectable (n = 14, 26.4% vs. n = 1, 50%, p = 0.47) and undetectable (n = 14, 26.4% vs. n = 1, 50%, p = 0.47). Among the two recipients with CMV colitis, one had CMV DNAemia and the other had no CMV DNAemia upon the development of symptoms; negative anti-CMV-IgM and positive anti-CMV-IgG were observed both pre-transplant and post-transplant; finally, CMV colitis was documented based on the presence of inclusion bodies and positive immunohistochemistry (IHC) staining in histology. Conclusion: Patients with immunocompromised status, in particular organ transplantation, may have positive serum anti-CMV IgM/IgG antibodies both before and after transplantation. This study emphasized the fact that endoscopic biopsy with IHC staining may be a more powerful tool for making an accurate diagnosis of CMV colitis in the setting of living donor liver transplantation.
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Affiliation(s)
- Shu-Hsien Lin
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan 123 Ta-Pei Road, Niao-Sung District, Kaohsiung 833, Taiwan
- Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Kun-Ta Wu
- Division of General Surgery, Department of Surgery, E-Da Hospital, Kaohsiung 833, Taiwan
| | - Chih-Chi Wang
- Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- Division of General Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Ting-Ting Liu
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Hock-Liew Eng
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - King-Wah Chiu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan 123 Ta-Pei Road, Niao-Sung District, Kaohsiung 833, Taiwan
- Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
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10
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Risk Factors, Clinical and Endoscopic Features, and Clinical Outcomes in Patients with Cytomegalovirus Esophagitis. J Clin Med 2022; 11:jcm11061583. [PMID: 35329909 PMCID: PMC8955160 DOI: 10.3390/jcm11061583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/01/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Cytomegalovirus (CMV) esophagitis is the second most common CMV disease of the gastrointestinal tract. This study aims to comprehensively analyze risk factors, clinical characteristics, endoscopic features, outcomes, and prognostic factors of CMV esophagitis. We retrospectively collected data of patients who underwent esophageal CMV immunohistochemistry (IHC) staining between January 2003 and April 2021 from the pathology database at the Chang Gung Memorial Hospital. Patients were divided into the CMV and non-CMV groups according to the IHC staining results. We enrolled 148 patients (44 CMV and 104 non-CMV patients). The risk factors for CMV esophagitis were male sex, immunocompromised status, and critical illness. The major clinical presentations of CMV esophagitis included epigastric pain (40.9%), fever (36.4%), odynophagia (31.8%), dysphagia (29.5%), and gastrointestinal bleeding (29.5%). Multiple diffuse variable esophageal ulcers were the most common endoscopic feature. The CMV group had a significantly higher in-hospital mortality rate (18.2% vs. 0%; p < 0.001), higher overall mortality rate (52.3% vs. 14.4%; p < 0.001), and longer admission duration (median, 24 days (interquartile range (IQR), 11−47 days) vs. 14 days (IQR, 7−24 days); p = 0.015) than the non-CMV group. Acute kidney injury (odds ratio (OR), 174.15; 95% confidence interval (CI), 1.27−23,836.21; p = 0.040) and intensive care unit admission (OR, 26.53; 95% CI 1.06−665.08; p = 0.046) were predictors of in-hospital mortality. In conclusion, the mortality rate of patients with CMV esophagitis was high. Physicians should be aware of the clinical and endoscopic characteristics of CMV esophagitis in high-risk patients for early diagnosis and treatment.
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11
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Cytomegalovirus Diseases of the Gastrointestinal Tract. Viruses 2022; 14:v14020352. [PMID: 35215942 PMCID: PMC8879032 DOI: 10.3390/v14020352] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 02/04/2023] Open
Abstract
Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract can be fatal. However, very few studies have provided comprehensive analyses and specified the differences in symptoms observed in different parts of the GI tract. This study aimed to comprehensively analyze clinical manifestations and management of GI CMV disease. This retrospective cohort study enrolled the patients who had CMV diseases of the GI tract proved by CMV immunohistochemistry stain from the pathology database in a 4000-bed tertiary medical center between January 2000 and May 2021. The patient characteristics, clinical manifestations, endoscopic features, treatments, outcomes, and prognostic factors were analyzed. A total of 356 patients were enrolled, including 46 infected in the esophagus, 76 in the stomach, 30 in the small intestine, and 204 in the colon. In total, 49.4% patients were immunocompromised. The overall in-hospital mortality rate was 20.8%: CMV enteritis had the highest rate (23.3%). Sixty percent of patients received antiviral treatment and 16% were administered both intravenous and oral anti-viral drugs (Combo therapy, minimal and mean treatment duration were 14 and 39.9 ± 25 days). Prognostic factors of in-hospital mortality included age, immune status, albumin level, platelet count, GI bleeding, time-to-diagnosis, and Combo therapy. In the survival analysis, immunocompetent patients receiving Combo therapy had the best survival curve, and immunocompromised patients receiving non-Combo therapy had the worst survival curve. Combo therapy ≥14 days resulted in a better outcome for both immunocompromised and immunocompetent patients. In conclusion, CMV GI diseases affect both immunocompromised and immunocompetent hosts, and a complete treatment course should be considered for patients with poor prognostic factors.
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12
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Jena A, Mishra S, Singh AK, Sekar A, Sharma V. Cytomegalovirus in ulcerative colitis: an evidence-based approach to diagnosis and treatment. Expert Rev Gastroenterol Hepatol 2022; 16:109-120. [PMID: 35057693 DOI: 10.1080/17474124.2022.2032662] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The detection of cytomegalovirus (CMV) in the setting of inflammatory bowel disease often creates confusion whether CMV is a 'bystander' or 'disease.' AREAS COVERED This review discusses the clinical conundrum of CMV in ulcerative colitis, approach to discriminate infection from disease, and therapeutic considerations (immunosuppressive and anti-CMV treatment). CMV disease should be considered in corticosteroid refractory- dependent and thiopurine refractory disease. Endoscopy may reveal deep punched out ulcers, irregular ulcers, or cobble-stoning. The diagnosis rests on the presence and abundance of viral inclusion bodies on hematoxylin and eosin stain, positive immunohistochemistry, and/or positive tissue polymerase chain reaction. CMV disease is associated with worse outcomes including increased colectomy rates. EXPERT OPINION The timing and duration of antiviral drugs in CMV disease is debatable but depends on the load of CMV in tissue. In high-grade infection, CMV needs to be treated while increasing immunosuppression may work in the setting of low-grade infection. Ganciclovir is the drug of choice for treatment of CMV disease. Tumor necrosis factor inhibitors may be useful for treating underlying disease activity in the setting of CMV. Other emerging therapies include fecal microbiota transplantation. Randomized studies are necessary to define the best timing and duration of anti-CMV therapy.
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Affiliation(s)
- Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shubhra Mishra
- Department of Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Anupam Kumar Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aravind Sekar
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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13
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Christensen BW, Li HC, Huerta S. Blurred Vision and Gastrointestinal Bleeding in a Patient With HIV. JAMA 2022; 327:276-277. [PMID: 35040904 DOI: 10.1001/jama.2021.21510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Bradley W Christensen
- Division of Hematology and Oncology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Hsiao C Li
- Division of Hematology and Oncology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Sergio Huerta
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
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