Clinical, imaging, endoscopic findings, and management of patients with CMV colitis: a single-institute experience

Gastrointestinal cytomegalovirus infection in persons with HIV: a retrospective case series study

BACKGROUND

Gastrointestinal (GI) cytomegalovirus (CMV) infection remains an important cause of morbidity among persons with HIV (PWH), even in the late antiretroviral therapy (ART) era. However, its varied clinical presentations and outcomes are not fully understood.

METHODS

We conducted a retrospective review of 21 PWH with histologically confirmed GI-CMV infections admitted to a tertiary hospital in Nanjing, China, between September 2018 and September 2023. Clinical features, endoscopic findings, histology, treatment responses, and outcomes were examined.

RESULTS

Patients were predominantly male (95.2%) with a median age of 42 years. Over 80% had CD4 cell counts below 50 cells/µL; at admission, they were not on effective ART or had only recently initiated it, with a median HIV viral load of 5.2 log copies/mL (IQR: 4.9-5.7). Diarrhea (71.4%) was the most common presentation, followed by fever (52.4%), abdominal pain (47.6%), and GI bleeding (38.1%). The median symptom duration was 2.0 months (IQR: 1.0-5.0). Nearly half the patients had concurrent CMV end-organ disease-most commonly CMV retinitis-and 95.2% had at least one AIDS-defining illness; GI mycobacterial co-infection was found in three patients. The colon was the most frequently affected GI site, followed by the stomach and esophagus. Endoscopic findings included ulcers, erosions, proliferative lesions, and diffuse mucosal hemorrhage. All patients initially received intravenous ganciclovir and/or foscarnet for a median of 30 days (IQR: 20-39). The 9 patients with CMV retinitis were given oral ganciclovir maintenance. Gastrointestinal surgery was needed in 9.5% of cases. The 6-month mortality rate was 4.8%.

CONCLUSION

GI-CMV infection primarily affects PWH with profound immunosuppression (CD4 < 50 cells/µL) and inadequate or absent ART. These patients frequently have other AIDS-defining illnesses and CMV end-organ diseases, complicating their management. For PWH with GI-CMV infection, clinicians should address not only CMV itself but also coexisting conditions arising from advanced immunodeficiency to improve outcomes.

[Translated article] AEDVAEDV Expert Recommendations on the Management of Suppurative Sexually Transmitted Infections

The incidence of sexually transmitted infections (STIs) is increasing in Spain. Suppurative STIs are one of the most frequent reasons for consultation in specialized centers. The reason for suppurative STIs is multiple and their empirical treatment varies with the currently growing problem of antimicrobial resistance. Dermatologists are trained and prepared to treat these diseases, but their correct management requires active knowledge of national and international guidelines. The present document updates, reviews and summarizes the main expert recommendations on the management and treatment of these STIs.

AEDV Expert Recommendations on the Management of Suppurative Sexually Transmitted Infections

The incidence of sexually transmitted infections (STIs) is increasing in Spain. Suppurative STIs are one of the most frequent reasons for consultation in specialized centers. The reason for suppurative STIs is multiple and their empirical treatment varies with the currently growing problem of antimicrobial resistance. Dermatologists are trained and prepared to treat these diseases, but their correct management requires active knowledge of national and international guidelines. The present document updates, reviews and summarizes the main expert recommendations on the management and treatment of these STIs.

Cytomegalovirus Enterocolitis in a Patient Treated with Methylprednisolone for Amiodarone Hypersensitivity Pneumonitis

Cytomegalovirus (CMV) is a common cause of infection in immunocompromised individuals, such as patients with hematological malignancies or AIDS, but can also occur in patients with other acquired immunodeficiencies. In tissue-invasive diseases, CMV diagnosis requires CMV DNA in the plasma and the histological confirmation of CMV in a tissue or organ. Evidence of CMV colitis requires a characteristic endoscopic picture with ulcers with a well-defined, convex appearance and CMV viral inclusions in the form of an "owl's eye" on mucosal sections stained with hematoxylin and eosin. CMV-specific immunohistochemistry is the gold standard for identifying CMV in tissue biopsies. It is important to consider a CMV infection in the diagnostic process, as it may delay the diagnosis and the treatment. We present the case of a 78-year-old patient with amiodarone interstitial lung disease who was treated with methylprednisolone. Two weeks after the start of his treatment, he was admitted to the hospital for acute gastroenterocolitis and Addisonian crisis. An examination had confirmed a tissue-invasive CMV disease. He was treated with valganciclovir for a total of six weeks. After the completion of treatment, the patient showed no clinical signs of CMV infection, and both laboratory and histological examinations revealed no residual CMV disease. Tissue-invasive CMV disease can occur in patients with acquired immunodeficiency, which may result from various causes, including glucocorticoid treatment.

Gastrointestinal Ultrasound in Infectious Diseases: A Comprehensive Review

Infectious diseases affecting the gastrointestinal tract often present diagnostic challenges due to the variability in clinical manifestations and overlapping symptoms. Ultrasound imaging has emerged as a valuable tool in the assessment of gastrointestinal pathologies, offering non-invasive and real-time visualization of anatomical structures. This review aims to explore the role of ultrasound in the diagnosis and management of infectious diseases involving the gastrointestinal tract. We discuss the imaging features of various infectious etiologies, such as bacterial, viral, and parasitic infections, highlighting characteristic findings on ultrasound scans. Additionally, we provide insights into the utility of ultrasound for the assessment of treatment response. Through a comprehensive analysis of existing literature and clinical case studies, this review underscores the significance of ultrasound imaging as a frontline modality in the diagnosis and management of infectious diseases affecting the gastrointestinal tract.

Integrating transcriptomics and proteomics to analyze the immune microenvironment of cytomegalovirus associated ulcerative colitis and identify relevant biomarkers

BACKGROUND

In recent years, significant morbidity and mortality in patients with severe inflammatory bowel disease (IBD) and cytomegalovirus (CMV) have drawn considerable attention to the status of CMV infection in the intestinal mucosa of IBD patients and its role in disease progression. However, there is currently no high-throughput sequencing data for ulcerative colitis patients with CMV infection (CMV + UC), and the immune microenvironment in CMV + UC patients have yet to be explored.

METHOD

The xCell algorithm was used for evaluate the immune microenvironment of CMV + UC patients. Then, WGCNA analysis was explored to obtain the co-expression modules between abnormal immune cells and gene level or protein level. Next, three machine learning approach include Random Forest, SVM-rfe, and Lasso were used to filter candidate biomarkers. Finally, Best Subset Selection algorithms was performed to construct the diagnostic model.

RESULTS

In this study, we performed transcriptomic and proteomic sequencing on CMV + UC patients to establish a comprehensive immune microenvironment profile and found 11 specific abnormal immune cells in CMV + UC group. After using multi-omics integration algorithms, we identified seven co-expression gene modules and five co-expression protein modules. Subsequently, we utilized various machine learning algorithms to identify key biomarkers with diagnostic efficacy and constructed an early diagnostic model. We identified a total of eight biomarkers (PPP1R12B, CIRBP, CSNK2A2, DNAJB11, PIK3R4, RRBP1, STX5, TMEM214) that play crucial roles in the immune microenvironment of CMV + UC and exhibit superior diagnostic performance for CMV + UC.

CONCLUSION

This 8 biomarkers model offers a new paradigm for the diagnosis and treatment of IBD patients post-CMV infection. Further research into this model will be significant for understanding the changes in the host immune microenvironment following CMV infection.

Gastrointestinal Manifestations of Immunodeficiency: Imaging Spectrum

There is a wide spectrum of hereditary and acquired immunodeficiency disorders that are characterized by specific abnormalities involving a plethora of humoral, cellular, and phagocytic immunologic pathways. These include distinctive primary immunodeficiency syndromes due to characteristic genetic defects and secondary immunodeficiency syndromes, such as AIDS from HIV infection and therapy-related immunosuppression in patients with cancers or a solid organ or stem cell transplant. The gut mucosa and gut-associated lymphoid tissue (the largest lymphoid organ in the body), along with diverse commensal microbiota, play complex and critical roles in development and modulation of the immune system. Thus, myriad gastrointestinal (GI) symptoms are common in immunocompromised patients and may be due to inflammatory conditions (graft versus host disease, neutropenic enterocolitis, or HIV-related proctocolitis), opportunistic infections (viral, bacterial, fungal, or protozoal), or malignancies (Kaposi sarcoma, lymphoma, posttransplant lymphoproliferative disorder, or anal cancer). GI tract involvement in immunodeficient patients contributes to significant morbidity and mortality. Along with endoscopy and histopathologic evaluation, imaging plays an integral role in detection, localization, characterization, and distinction of GI tract manifestations of various immunodeficiency syndromes and their complications. Select disorders demonstrate characteristic findings at fluoroscopy, CT, US, and MRI that permit timely and accurate diagnosis. While neutropenic enterocolitis affects the terminal ileum and right colon and occurs in patients receiving chemotherapy for hematologic malignancies, Kaposi sarcoma commonly manifests as bull's-eye lesions in the stomach and duodenum. Imaging is invaluable in treatment follow-up and long-term surveillance as well. Online supplemental material is available for this article. ^©RSNA, 2022.

Cytomegalovirus-associated pseudomembranous colitis in a kidney transplant recipient

Pseudomembranous colitis (PMC) is classically associated with Clostridium difficile infection. We report a rare case of cytomegalovirus (CMV)-associated PMC in a 52-year-old female patient who had undergone kidney transplantation more than 20 years ago and was on low dose prednisolone and ciclosporin. She presented with an acute history of fever, lethargy, vomiting and diarrhoea on admission. Computed tomography of the abdomen showed extensive colitis, and colonoscopy revealed extensive pseudomembrane formation. Multiple tests for Clostridium difficile and other common microbiological causes of colitis were negative. CMV DNAemia and colonic biopsies confirmed the diagnosis of CMV colitis. The patient responded to prompt CMV treatment, as demonstrated by clinical, endoscopic, and histological response. While CMV is a common pathogen in the solid organ transplant population that is familiar to most transplant physicians, it may present atypically as PMC. Here, we review the literature on CMV-associated PMC and its relevance to solid organ transplant recipients. To our knowledge, this is the first reported case of CMV-associated PMC in a kidney transplant recipient.

2021 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens

This guideline intents to offer guidance on the diagnosis and management of patients with gastrointestinal symptoms and a suspected sexually transmitted cause. Proctitis is defined as an inflammatory syndrome of the anal canal and/or the rectum. Infectious proctitis can be sexually transmitted via genital-anal mucosal contact, but some also via digital contact and toys. Neisseria gonorrhoeae, Chlamydia trachomatis (including lymphogranuloma venereum), Treponema pallidum and herpes simplex virus are the most common sexually transmitted anorectal pathogens. Shigellosis can be transferred via oral-anal contact and may lead to proctocolitis or enteritis. Although most studies on these infections have concentrated on men who have sex with men (MSM), women having anal intercourse may also be at risk. A presumptive clinical diagnosis of proctitis can be made when there are symptoms and signs, and a definitive diagnosis when the results of laboratory tests are available. The symptoms of proctitis include anorectal itching, pain, tenesmus, bleeding, constipation and discharge in and around the anal canal. The majority of rectal chlamydia and gonococcal infections are asymptomatic and can only be detected by laboratory tests. Therefore, especially when there is a history of receptive anal contact, exclusion of anorectal infections is generally indicated as part of standard screening for sexually transmitted infections (STIs). Condom use does not guarantee protection from STIs, which are often spread without penile penetration. New in this updated guideline is: (i) lymphogranuloma venereum proctitis is increasingly found in HIV-negative MSM, (ii) anorectal Mycoplasma genitalium infection should be considered in patients with symptomatic proctitis after exclusion of other common causations such N. gonorrhoeae, C. trachomatis, syphilis and herpes, (iii) intestinal spirochetosis incidentally found in colonic biopsies should not be confused with syphilis, and (iv) traumatic causes of proctitis should be considered in sexually active patients.

Ultrasonography in infectious and neoplastic diseases of the bowel and peritoneum

Ultrasonography is not the most cited imaging technique for the evaluation of infectious and neoplastic diseases of the gastrointestinal tract and the peritoneum, but it is often the initial technique used in the initial workup for nonspecific clinical syndromes. Despite its limitations, ultrasonography's strengths enable it to provide meaningful diagnostic information. To discuss the most important ultrasonographic, clinical, and epidemiological findings for infectious disease, we follow a topographical approach: stomach (Anisakis), proximal small bowel (Giardia lamblia, Strongyloides stercoralis, Mycobacterium avium-intracellulare complex, and Cryptosporidium), distal small bowel (Yersinia, Salmonella, and Campylobacter), terminal ileum and cecum (tuberculosis), right colon (Entamoeba histolytica), left colon (Shigella), sigmoid colon and rectum, pancolitis (Clostridium difficile, Cytomegalovirus, and Escherichia coli), and peritoneum. To discuss the ultrasonographic and clinical findings of the most common neoplastic diseases, we follow a nosological approach: polyploid lesions as precursors of tumors, carcinomas, neuroendocrine tumors, hematological tumors, mesenchymal tumors, and metastases. We briefly discuss tumors of the peritoneum and the use of ultrasonography to guide percutaneous biopsy procedures.