1
|
Kim S, Yoon KW, Gil E, Yoo K, Choi KJ, Park CM. Emergency gastrointestinal tract operation associated with cytomegalovirus infection. Ann Surg Treat Res 2023; 104:119-125. [PMID: 36816733 PMCID: PMC9929438 DOI: 10.4174/astr.2023.104.2.119] [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] [Revised: 11/25/2022] [Accepted: 12/05/2022] [Indexed: 02/10/2023] Open
Abstract
Purpose Cytomegalovirus (CMV) infection is common in immunocompromised patients. Enterocolitis caused by CMV infection can lead to perforation and bleeding of the gastrointestinal (GI) tract, which requires emergency operation. We investigated the demographics and outcomes of patients who underwent emergency operation for CMV infection of the GI tract. Methods This retrospective study was conducted between January 2010 and December 2020. Patients who underwent emergency GI operation and were diagnosed with CMV infection through a pathologic examination of the surgical specimen were included. The diagnosis was confirmed using immunohistochemical staining and evaluated by experienced pathologists. Results A total of 27 patients who underwent operation for CMV infection were included, 18 of whom were male with a median age of 63 years. Twenty-two patients were in an immunocompromised state. Colon (37.0%) and small bowel (37.0%) were the most infected organs. CMV antigenemia testing was performed in 19 patients; 13 of whom showed positive results. The time to diagnose CMV infection from operation and time to start ganciclovir treatment were median of 9 days. The reoperation rate was 22.2% and perforation was the most common cause of reoperation. In-hospital mortality rate was 25.9%. Conclusion CMV infection in the GI tract causes severe effects, such as hemorrhage or perforation, in immunocompromised patients. When these outcomes are observed in immunocompromised patients, suspicion of CMV infection and further evaluation for CMV detection in tissue specimens is required for proper treatment.
Collapse
Affiliation(s)
- Seijong Kim
- Division of Colorectal Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung Won Yoon
- Division of Critical Care, Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Eunmi Gil
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keesang Yoo
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Jin Choi
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi-Min Park
- Division of Acute Care Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
2
|
Yamamoto T, Endo D, Shimada A, Matsushita S, Asai T, Amano A. Surgical treatment of acute aortic dissection in a patient with SLE and prior antiphospholipid syndrome on therapy for over 30 years: a case report. BMC Cardiovasc Disord 2022; 22:216. [PMID: 35562652 PMCID: PMC9103044 DOI: 10.1186/s12872-022-02659-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 05/02/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In patients with systemic lupus erythematosus (SLE), lengthy treatment and long-term steroid use are the main risk factors for developing aortic aneurysms or aortic dissections. In patients with cardiac tamponade, hemodynamic collapse may lead to acute renal and hepatic failure. CASE PRESENTATION We report the successful treatment of a 55-year-old woman with SLE since the age of 21. She suddenly felt chest pain approximately 2 weeks before developing fever and vomiting and was admitted to our hospital. Initially, she had severe liver dysfunction and was admitted to the hepatology department, where treatment for fulminant hepatitis was initiated. However, computed tomography (CT) showed an acute aortic dissection (DeBakey type II) and severe bloody pericardial effusion. Therefore, we performed emergency pericardial drainage. Plasma exchange therapy was initiated as emergency aortic surgery was deemed impossible due to impaired liver function tests and coagulation. Ten days later, the patient developed peritonitis due to small bowel perforation, and laparotomy was performed for abscess drainage and perforation closure. She had received steroid pulse therapy at the age of 21. At 40 years of age, she developed deep vein thrombosis due to antiphospholipid antibodies and was prescribed prednisolone. She was ambulatory at 3 months after the onset of acute aortic dissection, and CT revealed a rapidly enlarging true aneurysm in the distal arch. We performed elective aortic surgery. Although there were no antiphospholipid antibodies, surgery could have led to a devastating antiphospholipid syndrome. Therefore, we decided to treat the patient with triple therapy. Methylprednisolone was intravenously administered intraoperatively and at 1 day postoperatively. The patient was discharged without complications after returning to her usual oral prednisolone regimen. CONCLUSIONS The patient described herein had a systemic circulatory failure due to cardiac tamponade, accompanied by liver failure. This condition is a significant cause of death in patients with aortic dissection-associated SLE and is extremely dangerous. However, multi-specialty intervention helped the patient recover, and she has been attending the outpatient clinic. Aortic surgery requiring hypothermia in SLE patients with antiphospholipid syndrome and a history of thrombocytopenia or thrombosis requires a multi-disciplinary treatment team, including cardiac surgeons and medical experts.
Collapse
Affiliation(s)
- Taira Yamamoto
- Department of Cardiovascular Surgery, Juntendo Nerima Hospital, Takanodai 3-1-10, Nerima- Ku, Tokyo, 177-8521, Japan.
| | - Daisuke Endo
- Department of Cardiovascular Surgery, Juntendo University, Hongo 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Akie Shimada
- Department of Cardiovascular Surgery, Juntendo Nerima Hospital, Takanodai 3-1-10, Nerima- Ku, Tokyo, 177-8521, Japan
| | - Satoshi Matsushita
- Department of Cardiovascular Surgery, Juntendo University, Hongo 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University, Hongo 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsushi Amano
- Department of Cardiovascular Surgery, Juntendo University, Hongo 2-1-1, Bunkyo-ku, Tokyo, 113-8421, Japan
| |
Collapse
|
3
|
Valenzuela A, Rieger KE, Blish CA, Chung L, Fiorentino D. Gastrointestinal Perforation in a Patient With Antinuclear Matrix Protein 2 Antibody-Positive Dermatomyositis. Arthritis Care Res (Hoboken) 2022; 74:1409-1415. [PMID: 35287251 DOI: 10.1002/acr.24879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/23/2022] [Accepted: 03/08/2022] [Indexed: 11/08/2022]
Affiliation(s)
| | - Kerri E Rieger
- Stanford University School of Medicine, Redwood City, California
| | | | - Lorinda Chung
- Stanford University School of Medicine, Redwood City, California
| | - David Fiorentino
- Stanford University School of Medicine, Redwood City, California
| |
Collapse
|
4
|
Latif E, Musthafa S, Ahmed A, Abu Amr A. Stercoral Perforation of Sigmoid Colon in Systemic Lupus Erythematosus: A Rare Cause of Peritonitis. Cureus 2020; 12:e9495. [PMID: 32879819 PMCID: PMC7458703 DOI: 10.7759/cureus.9495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Stercoral perforation (SP) is a rare cause of peritonitis. It is caused by pressure necrosis of the colonic wall by fecaloma. SP is a lethal condition that is associated with high morbidity and mortality, therefore early diagnosis and treatment are of paramount importance. Herein, we describe a case of SP in a systemic lupus erythematosus (SLE) patient. A 44-year-old female, known case of SLE, presented with severe abdominal pain, fever, and hypotension. CT scan showed features of perforated sigmoid. The patient underwent exploratory laparotomy which revealed perforation of sigmoid, fecalomas in the peritoneal cavity, and colon loaded with fecal matter. The patient underwent Hartmann's operation with successful control of her intra-abdominal sepsis. Her postoperative course was complicated by SLE flare and wound dehiscence which was probably due to long term steroid use. Even though SP is rare, it carries a worse prognosis especially if the patients are immunocompromised. The key to successfully manage such cases is early diagnosis, aggressive resuscitation, antibiotics, and prompt surgical intervention. A multidisciplinary approach is often helpful in such cases.
Collapse
Affiliation(s)
- Ejaz Latif
- General Surgery, Hamad Medical Corporation, Doha, QAT
| | | | - Aryan Ahmed
- Acute Care Surgery, Hamad Medical Corporation, Doha, QAT
| | - Ahmad Abu Amr
- General Surgery, Hamad Medical Corporation, Doha, QAT
| |
Collapse
|
5
|
Meara A, Lamoreaux B, Steigleman H, Yedimenko J, Jarjour W, Rovin B, Parikh S, Ayoub I, Ardoin SP. Frequency of Cytomegalovirus Seropositivity and Viremia in a Midwestern University Lupus Population. J Clin Rheumatol 2020; 26:157-159. [PMID: 32453289 DOI: 10.1097/rhu.0000000000001390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Alexa Meara
- From the Department of Internal Medicine, and Division of Rheumatology and Immunology, Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Bhaskaran H, Balan S. Unusual cause for intestinal perforation in juvenile dermatomyositis. BMJ Case Rep 2019; 12:12/8/e229395. [PMID: 31444261 DOI: 10.1136/bcr-2019-229395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of juvenile dermatomyositis (JDM) with cytomegalovirus (CMV) colitis which was further complicated with perforation. The patient, a 6-year-old girl, was diagnosed with JDM 1 month prior to the current presentation. After 2 weeks of optimising her treatment with steroid, intravenous Ig and methotrexate, she was readmitted with diffuse abdominal pain. Erect abdominal X-ray revealed gas under diaphragm. An exploratory laparotomy showed perforation of the large intestine. A biopsy showed inclusion bodies of CMV with immunohistochemistry for CMV positive. Strong positive CMV DNA PCR from tissue specimen, positive IgG CMV and negative IgM CMV in blood suggested a reactivation of CMV. The treatment followed included surgery and strategic use of antiviral agents as well as immunomodulators. CMV enteritis with complications should also be suspected in optimally treated autoimmune disease patients, including JDM, when they present with abdominal symptoms.
Collapse
Affiliation(s)
- Harikrishnan Bhaskaran
- Department of Clinical Immunology and Rheumatology, Amrita Institute of Medical Sciences and Research Centre, Ernakulam, Kerala, India
| | - Suma Balan
- Department of Clinical Immunology and Rheumatology, Amrita Institute of Medical Sciences and Research Centre, Ernakulam, Kerala, India
| |
Collapse
|
7
|
A Practical Review of Cytomegalovirus in Gastroenterology and Hepatology. Gastroenterol Res Pract 2019; 2019:6156581. [PMID: 30984257 PMCID: PMC6431500 DOI: 10.1155/2019/6156581] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/05/2019] [Indexed: 02/06/2023] Open
Abstract
Human cytomegalovirus (CMV) is a ubiquitous Herpesviridae virus with a wide spectrum of pathology in humans. Host immunity is a major determinant of the clinical manifestation of CMV and can vary widely in the gastroenterology and hepatology practice setting. Immunocompetent patients generally develop a benign, self-limited mononucleosis-like syndrome whereas gastrointestinal tissue-invasive disease is more frequently seen in immunocompromised and inflammatory bowel disease patients. Additionally, liver allograft dysfunction is a significant consequence of CMV infection in liver transplant patients. While polymerase chain reaction and immunohistochemistry techniques allow for the reliable and accurate detection of CMV in the human host, the diagnostic value of different serologic, endoscopic, and histologic tests depends on a variety of factors. Similarly, latent CMV, CMV infection, and CMV disease carry different significance depending on the patient population, and the decision to initiate antiviral therapy can be complex and patient-specific. This review will focus on the pathophysiology, diagnosis, and management of CMV in patient populations relevant to the practice of gastroenterology and hepatology-liver transplant recipients, inflammatory bowel disease patients, and otherwise immunocompetent patients.
Collapse
|
8
|
Abstract
Cytomegalovirus (CMV) typically causes gastrointestinal infections in immunocompetent patients. Colonic perforations secondary to CMV are exceeding rare. We describe a 88-year-old male presenting with a week-long history of intractable abdominal discomfort, bloating, nausea and diarrhea. Flexible sigmoidoscopy revealed significant ulceration with yellowish slough. Emergency surgery was performed subsequently in view of multiple perforations in the rectosigmoid junction. CMV gastrointestinal infections demonstrated an ischemic process secondary to vasculitis, which accelerated the pathway to colonic perforation. CMV gastrointestinal infection should be considered as a differential diagnosis in patients with colonoscopy findings similar to ischemic colitis and Clostridium difficile infections.
Collapse
|
9
|
Soriano A, Smerieri N, Bonilauri S, De Marco L, Cavazza A, Salvarani C. Colonic perforation due to severe cytomegalovirus disease in granulomatosis with polyangiitis after immunosuppression. Clin Rheumatol 2018; 37:1427-1432. [PMID: 29302827 DOI: 10.1007/s10067-017-3945-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/26/2017] [Accepted: 12/04/2017] [Indexed: 12/19/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a small-vessel necrotizing granulomatous vasculitis typically involving upper airways, lungs, and kidneys, which may lead to end-organ damage and life-threatening complications. Major infections during GPA course represent a considerable concern in the management of the disease. Cytomegalovirus (CMV) infection and disease are rare but significant complications in the course of GPA being associated with high morbidity and mortality rates. Colonic perforation due to CMV colitis is exceedingly rare and has so far almost exclusively been documented in HIV, renal transplant, and systemic lupus erythematosus patients. We reported the case of a patient affected with upper airways-limited GPA who developed acute renal failure from rapidly progressive glomerulonephritis and then experienced colonic perforation due to CMV colitis a few weeks after immunosuppressive treatment with high-dose steroids and cyclophosphamide (CYC) for remission induction of the disease. We also reviewed the literature on CMV-related gastro-intestinal complications in the course of GPA and discussed contributing factors to severe manifestations of CMV infection and its reactivation.
Collapse
Affiliation(s)
- Alessandra Soriano
- Rheumatology Unit, Department of Internal Medicine, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy. .,Campus Bio-Medico University, Rome, Italy.
| | - Nazareno Smerieri
- General and Emergency Surgery, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy.
| | - Stefano Bonilauri
- General and Emergency Surgery, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy
| | - Loredana De Marco
- Pathology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy
| | - Alberto Cavazza
- Pathology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Department of Internal Medicine, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Viale Risorgimento 80, 42122, Reggio Emilia, Italy
| |
Collapse
|
10
|
The association of novel IL-33 polymorphisms with sIL-33 and risk of systemic lupus erythematosus. Mol Immunol 2016; 77:1-7. [DOI: 10.1016/j.molimm.2016.07.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 06/29/2016] [Accepted: 07/03/2016] [Indexed: 11/22/2022]
|