Ileal ulcers and cytomegalovirus infection in a case of Churg-Strauss syndrome

Factors associated with cytomegalovirus infection in antineutrophil cytoplasmic antibody-associated vasculitis: A narrative review

Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are vulnerable to opportunistic infections, including cytomegalovirus (CMV) infection. This narrative review aims to identify factors associated with CMV infection in patients with AAV. The literature review was conducted on Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, PubMed, Scopus, and Web of Science. The start date of the literature search was unrestricted and the end date was February 2022. CMV infection was defined as (a) CMV pp65 antigenemia or positive CMV DNA viral load by polymerase chain reaction or CMV detection on histological specimens, with associated signs and symptoms compatible with CMV infection; (b) presence of CMV clinical syndrome (defined as presence of compatible symptoms and signs and documentation of CMV by biopsy by virus isolation, rapid culture, immunohistochemistry, or DNA in biopsy material as defined by the CMV Drug Development Forum); and (c) CMV infection as coded by the International Statistical Classification of Diseases and Related Health Problems, 10th revision with at least one prescription for CMV treatment. We identified 4505 articles, of which three (2327 patients with AAV) were included. All studies were retrospective and only one of the three studies included only patients with AAV. Low or decreasing lymphocyte counts and higher prednisolone usage were associated with CMV infection in patients with AAV. Patients with AAV with lymphopenia and on high doses of prednisolone should be monitored closely for signs and symptoms of CMV infection, and might benefit from CMV prophylaxis. Prospective studies are urgently needed to better identify causes of CMV infections in patients with AAV.

Case report of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE): a rare disease may contribute to endoscopy-capsule retention in the small intestine

Background

CMUSE is a rare disease whose diagnosis remains difficult because the lesion is confined to the small bowel.

Case presentation

Here, we present a case of 43-year-old female patient suffered chronic abdominal pain for 20 years, and finally diagnosed with CMUSE. Capsule endoscopy was performed when general endoscopic investigation failed to find the lesion, but the capsule was stranded in the small intestine. Moreover, capsule retention results in acute intestinal obstruction. Thus, surgery was performed and CMUSE was confirmed. The patient was recovered after partial small intestine resection.

Conclusions

Capsule retention occurred in nearly 60% of patients with CMUSE. Capsule endoscopy should be avoided when the patient is suspected of CMUSE, especially with severe anemia and radiologic finding in the ileum.

Severe Cryptogenic Multifocal Ulcerous Stenosing Enteritis. A Report of Three Cases and Review of the Literature

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare condition characterised by chronic or relapsing moderate ileous episodes resulting from multiple small intestinal strictures, multiple shallow ulcers of the small bowel and favourable therapeutical effect of glucocorticosteroids. The aim of this paper was to evaluate three cases of CMUSE diagnosed within 10 years at a tertiary gastroenterology centre. Three females (35, 50, 60 years) were presented with colicky pain, repeated moderate ileous episodes and weight loss. Multiple fibrous strictures and ulcers of the small bowel were found. All three patients responded to glucocorticosteroid treatment. Tandem tight jejunal stenoses were dilated endoscopically by means of double balloon enteroscopy. In conclusion, CMUSE should always be considered when chronic moderate ileous episodes and multiple small intestinal strictures and ulcers of uncertain aetiology are found. Double balloon enteroscopy enables precise diagnostic work, possible endoscopic treatment of stenoses, may obviate the need for surgery and prevent excessive small bowel resections.

Small bowel involvement documented by capsule endoscopy in Churg-Strauss syndrome

Churg-Strauss syndrome is a small and medium vessel vasculitis and is also known as allergic granulomatous angiitis. Gastrointestinal involvement is common in patients with Churg-Strauss syndrome (20-50%). The most common symptoms are abdominal pain, diarrhoea and occasionally gastrointestinal bleeding and perforation. We present a case of Churg-Strauss syndrome with small bowel lesions documented by video capsule endoscopy.

Cryptogenic multifocal ulcerous stenosing enteritis: a review of the literature

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is an extremely rare illness characterised by chronic or relapsing subileus status resulting from multiple small intestinal fibrous strictures and multiple shallow ulcers of the small bowel. The etiology is unknown and pathogenesis is not fully understood. Therapy with systemic glucocorticosteroids is the treatment of choice. However, most patients develop corticosteroid dependence. Deep enteroscopy enables precise diagnostic work, possible endoscopic treatment of stenoses; may obviate the need for surgery and prevent excessive small bowel resections.

Churg-Strauss syndrome presenting as acute abdomen: are gastrointestinal manifestations an indicator of poor prognosis?

Churg Strauss syndrome (CSS) is a rare syndrome of vasculitis of the small to medium vessels, characterized by a triad of asthma, eosinophilia and atopic sinusitis. Although asthma is the most common manifestation, it is rarely associated with poor prognosis. Severe gastrointestinal tract manifestations are associated with worse outcomes. Patients with CSS at initial presentation, like our patient, may not meet all four American College of Rheumatology criteria to establish a diagnosis; however, clinicians should have a high index of suspicion to recognize the disease early in its course and treat aggressively, thereby decreasing the mortality and morbidity associated with this disease.

Sherlock Holmes in the ER (the case of red and the head)

A 58-year-old woman presented with a problem with her peripheral vision. Computed tomography scan showed an occipital hemorrhagic stroke. She subsequently suffered gastrointestinal bleeding and at surgery biopsy of a portion of the middle colic artery aneurysm revealed changes consistent with polyarteritis nodosa.

Vasculitis and the intensive care

Most frequent reasons for intensive care unit (ICU) admission in vasculitis patients are severe respiratory insufficiency due to diffuse alveolar haemorrhage, sepsis and/or pneumonia and an acute abdomen due to bowel infarction. Other reasons are massive gastrointestinal bleeding, thromboembolism and/or scissures. In a patient, not previously diagnosed as having vasculitis, diagnosis can be difficult and must be made as soon as possible, since immunosuppressive therapy should be instituted immediately. Immunosuppressive therapy in severe cases consists of high-dose corticosteroids and cyclophosphamide. In addition, in many cases plasma exchange has to be instituted as well. Prognosis is related to disease activity scores of vasculitis and of severity of illness as measured by the APACHE III scoring system and/or the SOFA score. Septic shock is still the leading cause of death in patients with vasculitis. Nowadays, death due to active untreated vasculitis is rare in experienced clinics.