Primary cytomegalovirus infection and gastric ulcers in normal host

Cytomegalovirus-Associated Gastroduodenal Ulcers in a Patient With Functional Hypercortisolism: A Case Report

Cytomegalovirus (CMV)-associated gastroduodenal ulcers (GDU) are a rare digestive disease, which principally affect immunocompromised patients. We recently experienced CMV-associated GDU occurring in a seemingly immunocompetent patient. The rarity of such a condition was inimical to a correct clinical diagnosis.A 77-year-old woman with Alzheimer's disease was admitted to our hospital because of vomiting and anorexia. Her general condition was extremely poor due to severe dehydration. Any invasive procedures including gastroduodenal endoscopy could not be performed. Laboratory test results showed electrolyte imbalance, hyperglycemia, and hypercortisolemia. The plasma adrenocorticotropic hormone level was rather low. On her 11th day in hospital, she suddenly fell into shock status. Despite intensive care, the patient could not be rescued. An autopsy was performed and revealed that she had suffered from CMV-associated GDU and died of candidemia that invaded through the ulcer. Her adrenal glands showed neither neoplasm nor hyperplasia, suggesting that her hypercortisolism was a purely functional disorder. We concluded that the severe opportunistic infections were developed in association with functional hypercortisolism.This case suggests that functional hypercortisolism, even though transient, can cause a patient to be immunocompromised.

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.

Review article: Helicobacter pylori-negative duodenal ulcer disease

BACKGROUND

Helicobacter pylori infection rates in duodenal ulcer (DU) patients may be lower than previously estimated.

AIM

To review the real prevalence of H. pylori-negative DUs and its possible causes.

METHODS

Bibliographical searches in MEDLINE looking for the terms 'H. pylori' and 'duodenal ulcer'.

RESULTS

Mean prevalence of H. pylori infection in DU disease, calculated from studies published during the last 10 years including a total of 16 080 patients, was 81%, and this figure was lower (77%) when only the last 5 years were considered. Associations with H. pylori-negative DU were: (1) False negative results of diagnostic methods, (2) NSAID use (21% in studies with <90% infection rate), (3) Complicated DU (bleeding, obstruction, perforation), (4) Smoking, (5) Isolated H. pylori duodenal colonization, (6) Older age, (7) Gastric hypersecretion, (8) Diseases of the duodenal mucosa, (9) Helicobacter'heilmanii' infection and (10) Concomitant diseases.

CONCLUSION

In patients with H. pylori-negative DU disease, one should carefully confirm that the assessment of H. pylori status is reliable. In truly H. pylori-negative patients, the most common single cause of DU is, by far, the use of NSAIDs. Ulcers not associated with H. pylori, NSAIDs or other obvious causes should, for the present, be viewed as 'idiopathic'. True idiopathic DU disease only exceptionally exists.

Cytomegalovirus-associated acute gastric mucosal lesion in an immunocompetent host

Involvement of the gastrointestinal tract in cytomegalovirus (CMV) infection is commonly observed in immunocompromised hosts. We encountered an immunocompetent patient with CMV associated-acute gastric mucosal lesion (AGML). The emergence of inclusion bodies characteristic of CMV infection in the specimens obtained from the patient's gastric ulcers was helpful in identifying the cause of AGML. The patient recovered without the administration of antiviral drugs. This case illustrates that CMV infection can be one of the causative agents that trigger AGML even in immunocompetent hosts, and that gastric biopsies are extremely useful for ascertaining the etiology of AGML.

Eosinophilic gastroenteritis with cytomegalovirus infection in an immunocompetent child

A 3-year-old boy developed transient protein-losing gastroenteropathy associated with cytomegalovirus (CMV) infection. Both IgG and IgM antibodies to CMV were positive in a serologic blood test. Upper gastrointestinal endoscopy showed multiple erosions throughout the body of the stomach, without enlarged gastric folds. Histological examination of the biopsy specimens indicated eosinophilic gastroenteritis and CMV infection. The patient had complete resolution without specific therapy for CMV in four weeks. An allergic reaction as well as CMV infection played important roles in the pathogenesis of this case.

Acute cytomegalovirus infection associated with the onset of inflammatory bowel disease

A 29-year-old man was admitted with high-grade fever, crampy abdominal pain, and watery diarrhea that had persisted for 2 weeks before his admission. Symptomatic treatment (acetaminophen only) was of no benefit. On physical examination, there was diffuse abdominal tenderness. Laboratory tests showed a leukomoid reaction with atypical lymphocytosis, and serology tests revealed acute cytomegalovirus infection. Abdominal computed tomography and colonoscopy revealed an inflammatory process involving the large intestine. On histologic examinations of intestinal biopsy samples, there was an active inflammation with no inclusion bodies. The patient was treated with ganciclovir with only mild improvement. Adding 5-aminosalicylic acid caused little further improvement. Repeated colonoscopy performed 2 months later showed severe chronic ulcerative colitis. Only the addition of systemic steroids caused complete resolution of the symptoms. On review of the literature (Medline search for cytomegalovirus colitis in immunocompetent patients), 18 cases were found. On follow-up, 10 of these patients were found to have inflammatory bowel disease.

Management of peptic ulcer disease not related to Helicobacter pylori or NSAIDs

Helicobacter pylori (H. pylori) infection is widely accepted as the most important factor in the pathogenesis of duodenal ulcer. However, in parallel with more effective eradication of H. pylori, the prevalence of H. pylori is changing, and H. pylori-negative peptic ulcer disease appears to be increasing. When making a diagnosis of H. pylori-negative peptic ulcer disease, it is essential to avoid misclassification because of inaccurate diagnosis. In addition, secondary causes may need to be excluded with appropriate investigations. In the absence of H. pylori, nonsteroidal anti-inflammatory drug usage is the most common cause of peptic ulcer; surreptitious nonsteroidal anti-inflammatory drug usage is a cause of unexplained ulcer disease in up to 60% of patients. Hypersecretory syndromes such as Zollinger-Ellison syndrome, although rare, need to be excluded. Once all known etiological factors are excluded, there remains a group of patients with so-called "idiopathic ulcers." The interplay of etiological factors in the pathogenesis of idiopathic peptic ulcer disease is poorly defined but may include a genetic predisposition, altered acid secretion, rapid gastric emptying, defective mucosal defense mechanisms, psychological stress, and smoking. The management of idiopathic peptic ulcers is not defined; they appear to be more resistant to standard therapy, can be associated with more frequent complications, and those that relapse may require long-term maintenance therapy.

HTLV-I carrier status disclosed at diagnosis of cytomegalovirus gastric ulcer

A 50-year-old man experienced epigastric pain and gastrofiberscopy (GF) disclosed A2 to H1 stage multiple ulcerative lesions in the stomach. Inclusion bodies were found in the gastric mucosal cells of the biopsy specimen and the cells were positive for monoclonal antibody against cytomegalovirus. Serum HTLV-I antibody was positive and no atypical lymphocytes were seen in the peripheral blood. Gancyclovir and lansoprazole were given. A follow-up GF showed good ulcer healing with immunohistological improvement. The patient died from acute hepatic failure of undetermined cause eleven months after diagnosis. This is the first case report where a cytomegaloviral-induced gastric ulcer disclosed HTLV-I carrier state.

Ileal perforation caused by cytomegalovirus infection in an immunocompetent adult

A 71-year-old woman developed a small bowel perforation due to cytomegalovirus infection. She did not taken any immunosuppressive medication and her cellular immunity was normal. Surgical resection and antiviral therapy with ganciclovir led to complete recovery. As far as we know, this paper reports the first case of small bowel perforation due to cytomegalovirus infection in a non-immunocompromised patient. Nevertheless the patient was known with diabetes mellitus. It should be emphasised that elderly patients have impaired immune defences and may be unsuspected hosts of opportunistic infections.

Cytomegalovirus Esophagitis as a Treatable Complication of Systemic Sclerosis

We report the case of a 51-year-old woman with a connective tissue disease of 8 years duration. She had been taking corticosteroids at a dose of 1 mg/kg/day and azathioprine at a dose of 3 mg/kg/day for 1 month. Given the clinical suspicion of systemic sclerosis (limited form of scleroderma), she was studied according to a protocol including endoscopy to assess the degree to which the underlying disease had affected the gastrointestinal tract. Endoscopy revealed a asymptomatic severe esophagitis and a subsequent biopsy disclosed the presence of cytomegalovirus. Cytomegalovirus pneumonia was also detected. Both processes were successfully managed with intravenous ganciclovir (5 mg/kg/12 hr) for 21 days. This report is a case of cytomegalovirus involving the esophagus in association with systemic sclerosis in a patient immunosuppressed because of drugs that she had been taking. This complication can be asymptomatic and is amenable to treatment.

Cytomegalovirus-associated gastric ulcer in an immunosuppressed patient with pemphigus vulgaris

A 79-year-old female with pemphigus vulgaris developed a cytomegalovirus (CMV)-associated gastric ulcer whilst on standard immunosupression with azathioprine and prednisolone. Following treatment with ganciclovir and ranitidine the ulcer healed. CMV infection frequently involves the gastrointestinal tract of immunocompromised patients causing inflammation, ulceration and haemorrhage. Although it has also been described in patients treated with immunosuppressive therapy for malignancy and other autoimmune disease, we are not aware of previous reports in patients treated for autoimmune bullous disease.

Cytomegalovirus hemorrhagic gastritis

A 36-year-old male with acquired immune deficiency syndrome (AIDS) presented with intractable nausea and vomiting of 1 week's duration that was not attributable to his medications. An esophagogastroduodenoscopy showed hemorrhagic and necrotic gastric mucosa but no ulcers were found. Histopathology revealed viral inclusions consistent with cytomegalovirus (CMV) disease of the stomach. The patient received 6 weeks of intravenous ganciclovir with resolution of symptoms and endoscopic findings. Cytomegaloviral involvement of the stomach is rare, even in immunocompromised patients. Characteristic findings on upper endoscopy are punched-out gastric ulcers. This is a rare case of CMV disease of the stomach presenting as hemorrhagic, necrotic gastritis with inflammatory bridging.

Peptic ulcer disease in children

A peptic ulcer in a child looks the same as it does in an adult, and many of the aetiologies of peptic ulcer disease in children are similar to those in adults. However, there are many differences between children and adults, especially in the areas of clinical presentation, the prevalences of different types of ulcer disease, and the prevalence of complications of ulcer disease. Therefore the approach to diagnosis and management in children is often at variance with that in adults. One important example is the approach to suspected Helicobacter pylori (H. pylori) disease in children, in which consensus groups have advised a considerably different approach in children. While the chapter deals with the full range of peptic ulcer disease in children, the focus is on those aspects in which there are differences between adults and children.

Evolution of acute cytomegalovirus gastritis to chronic gastrointestinal dysmotility in a nonimmunocompromised adult

A 30-year-old nonimmunocompromised woman developed chronic gastrointestinal dysmotility as a consequence of acute cytomegalovirus infection. The acute nature of the infection was documented by high immunoglobulin M antibody titer to cytomegalovirus (CMV); the chronicity of the infection was shown by persistence of CMV in biopsy specimens of her gastrointestinal tract over a 21/2-year period. Gastrointestinal dysmotility was confirmed by delayed emptying on gastric nuclear scintigraphy, by retrograde propagation of migrating myoelectric complexes on small intestinal manometry, and by presence of tachygastria on cutaneous electrogastrography. The patient's nausea, vomiting, abdominal pain, and early satiety resolved after a short course of treatment with leuprolide acetate but returned after medication was discontinued. Her symptoms persisted despite clearance of CMV from the gastrointestinal tract after a course of treatment with ganciclovir. These observations show that acute CMV infection can cause gastrointestinal dysmotility in nonimmunocompromised individuals and that the disturbance in gastrointestinal motor function may persist for years after viral infection of the gastrointestinal tract has been eradicated.

Cytomegalovirus mononucleosis--associated gastric ulcers in normal host

A case of cytomegalovirus (CMV) mononucleosis associated with gastric ulcers is reported in a normal non-immunocompromised host. The demonstration of intranuclear inclusion bodies in a few gastric glandular epithelial cells contributed to the diagnosis of CMV gastritis. Extraction of DNA from the gastric biopsy specimens and the amplification of CMV-DNA by the polymerase chain reaction (PCR) showed the presence of CMV-DNA in the gastric mucosa. In situ hybridization with a probe derived from CMV genomic regions demonstrated the numerous glandular cells with CMV-DNA at the nuclear region. Treatment with a proton pump inhibitor to suppress gastric acid secretion was useful to mitigate the epigastralgia and to hasten the ulcer healing. The value of highly sensitive PCR and the in situ hybridization method to detect the CMV-DNA were emphasized for rapid and sensitive diagnosis of CMV gastritis.