Cytomegalovirus infection presenting as isolated inflammatory polyps of the gastrointestinal tract

Association between human herpesviruses and head and neck squamous cell carcinoma: a molecular perspective

BACKGROUND

Head and neck cancer (HNC) is the seventh most common malignant tumor. Herpesviruses are a significant risk factor in the multifactorial pathogenesis of HNC.

OBJECTIVES

This study aimed to investigate the association between herpesviruses and the development of head and neck squamous cell carcinoma (HN-SCC).

DESIGN

Experimental study.

SETTING

A university hospital in Turkey.

PATIENTS AND METHODS

Pathological archive tissue samples of 500 patients were included in the study. These samples were categorized into two groups: those diagnosed with HN-SCC (n=300, malignant group [MG]) and those diagnosed with benign head and neck lesions (n=200, benign group [BG]). The presence of herpesvirus in samples was detected using polymerase chain reaction.

MAIN OUTCOME MEASURES

Association of herpesviruses in the development of head and neck cancer.

SAMPLE SIZE

500 patients.

RESULTS

HHV-1, -2, -7, and -8 were not detected in any samples. In the malignant group (MG), EBV-DNA was detected in 1 patient (0.3%) and HHV-6 DNA in 2 patients (0.6%), while in the benign group (BG), VZV-DNA was detected in 1 patient (0.5%), EBV-DNA in 3 patients (1.5%), CMV-DNA in 5 patients (2.5%), and HHV-6 DNA in 3 patients (1.5%). While no significant difference was found between the groups for VZV, EBV, and HHV-6, a statistically significant difference was found in favor of the benign group for CMV.

CONCLUSION

Although herpesvirus seroprevalence is relatively high in the population, the lack of viral genome in tissue samples indicates that other factors might be prominent in developing HN-SCC.

LIMITATION

The storage conditions of the sample used (paraffinized sample) may have negatively affected the detection frequency of HHVs.

Cytomegalovirus Isolated to a Colon Polyp in a Patient with Ulcerative Colitis on Ozanimod: A Case Report

Introduction

Cytomegalovirus (CMV) infection is a notable gastrointestinal infection affecting immunocompromised patients. In the gastrointestinal tract, CMV often presents with patchy or diffuse mucosal involvement and can cause fulminant colitis. However, polypoid CMV lesions are rare. We present a case of a 49-year-old man with ulcerative colitis (UC) in remission on ozanimod who developed CMV isolated to inflammatory colon polyps.

Case Presentation

A 49-year-old patient with UC in clinical remission on ozanimod underwent routine surveillance colonoscopy, which revealed multiple inflamed polyps with white caps. Biopsy results confirmed inflammatory polyps with positive CMV immunostaining, while adjacent tissues and plasma CMV PCR tests were negative. The patient successfully completed a 3-week course of valganciclovir. Follow-up colonoscopy revealed additional inflammatory polyps but no evidence of CMV. He remained in clinical remission and continued ozanimod therapy.

Conclusion

The unusual nature of this presentation suggests a clinically silent CMV reactivation or, alternatively, a primary CMV infection in our patient, with an unclear natural history and optimal management. This report emphasizes the importance of considering CMV in UC patients with unusual endoscopic findings and the need for multidisciplinary collaboration to optimize care.

Cytomegalovirus Diseases of the Gastrointestinal Tract in Immunocompetent Patients: A Narrative Review

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.

Pseudotumor presentation of CMV disease: Diagnostic dilemma and association with immunomodulating therapy

Cytomegalovirus (CMV) is a significant cause of morbidity and mortality in the immunocompromised host. Atypical presentations which include pseudotumors or "cancer mimics" have been described. The etiology of these lesions remains unclear. The authors describe two previously unpublished cases that have arisen in the context of newer immunomodulating therapy and review the existing non-HIV-associated CMV pseudotumors described in the literature.

Endoscopic mucosal resection of a large inflammatory fibroid polyp (Vanek's tumor): a case report

Vanek’s Tumor (inflammatory fibroid polyp) is a rare benign mesenchymal lesion occurring throughout the digestive tract. Classical Vanek’s tumor (“gastric”) contains concentric formations of proliferating spindle cells, which are CD34 positive. Atypical-inflammatory pseudotumor-like Vanek’s tumor (“intestinal”) lacks concentric formations and is CD34 negative. A 70-years-old man patient presented during hematochemical routine tests, sideropenic anemia and leukopiastrinosis. The patient performed osteomyelitis biopsy and esophagogastroduodenoscopy (EGD) showing a gastric wall with nodular appearance and, in antrum pre-pyloric, a polypoid pedunculated lesion, measuring approximately 3 cm in diameter, surrounded by hyperemic mucosa. The lesion then was removed by en bloc endoscopic mucosal resection (EMR) and histo-morphological, immune-cytochemical and biomolecular evaluations were performed. The data were compatible with a benign polyp fibroid inflammatory (Vanek’s Tumor). The results of this study suggest that endoscopic mucosal resection is a safe and efficacy solution for the resection of these gastrointestinal polyps and the two morphological patterns of Vanek’s tumor more probably represent only variants of one type of tumor than two different lesions. BRAF mutations were not shown growth PDGFRA wild-type Vanek’s tumor. (www.actabiomedica.it)

Development of a Predictive Model Using Endoscopic Features for Gastric Cytomegalovirus Infection in Renal Transplant Patients

BACKGROUND

Cytomegalovirus (CMV) is a common viral pathogen in transplant patients which often targets the stomach. However, the endoscopic characteristics of gastric CMV infection are not well established. We aimed to develop a predictive model using endoscopic findings for gastric CMV infection in renal transplant patients.

METHODS

A retrospective study of 287 kidney transplant recipients who underwent endoscopy with biopsy for suspected CMV infection from January 2006 to November 2015 at a tertiary referral hospital was performed. CMV infection was defined based on inclusion bodies in hematoxylin and eosin and immunohistochemical staining. Endoscopic and clinical parameters related to gastric CMV infection were selected by univariate analyses. Multivariate logistic regression was used to create a predictive model from β-coefficients.

RESULTS

CMV was present in 107 (37.7%) of the 287 patients. Multivariate analysis found age (odds ratio [OR], 0.964; 95% confidence interval [CI], 0.938-0.99; P = 0.008), erosions with surface exudate (OR, 5.34; 95% CI, 2.687-10.612; P < 0.001), raised shape of erosions (OR, 3.957; 95% CI, 1.937-8.083; P < 0.001), and antral location of ulcers (OR, 15.018; 95% CI, 5.728-39.371; P < 0.001) as independent predictive factors for gastric CMV infection. Using the predictive model created from this analysis, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 71.03%, 85.56%, 74.51%, 83.24%, and 80.14%, respectively. The area under the receiver operating characteristic curve of this model for detecting CMV infection was 0.850 (95% CI, 0.803-0.889; P < 0.001).

CONCLUSIONS

The predictive model with typical endoscopic findings may be useful for detecting gastric CMV infection in renal transplant patients.

CMV Colitis in Immunocompetent Patients: 2 Cases of a Diagnostic Challenge

CMV infections are generally thought to be opportunistic by immunosuppression. Many literature cases though indicate that CMV infections can be also observed in immunocompetent patients. We present an unusual case of an extensive concentric benign stenosis due to CMV colitis and a case of coexistence with Crohn's Disease, both observed in nonimmunosuppressed individuals. The right diagnosis was set after implementation of multiple unsuccessful treatment strategies. Our purpose is therefore to familiarize clinicians involved with the diagnosis and treatment of gastroenterological diseases with this entity.

Cytomegalovirus Colitis in a Critically Ill Patient Following Severe Legionella Pneumonia with Multiple Organ Failure

A 68-year-old man visited an emergency department complaining of dyspnea. He was diagnosed to have Legionella pneumonia with multiple organ failure. Although his multiple organ failure improved, he suffered from persistent abdominal pain and diarrhea with continuous minor bleeding. Colonoscopy revealed a longitudinal ulcer of the rectum, below the peritoneal reflection. He was diagnosed with cytomegalovirus (CMV) colitis. Antiviral therapy with ganciclovir was initiated. He finally underwent a colostomy after a bowel stricture caused an intestinal outlet obstruction, which made oral intake impossible. Based on the present case, we believe that CMV colitis must be considered as one of the differential diagnoses when critically ill patients develop continuous diarrhea and abdominal pain.

Gastrointestinal pathology in transplant patients

The assessment of gastrointestinal (GI) specimens from transplant patients is complicated by the wide range of potentially rare pathologies that may be found in this clinical setting. Acute GI graft-versus-host disease (GvHD) is characterized by epithelial cell apoptosis, although there is increasing recognition that acute and/or chronic inflammation may also be present. By contrast, thus far there are no histological features known to be specific to chronic GI GvHD. Mycophenolate mofetil colitis may mimic both GvHD and inflammatory bowel disease, whereas both cytomegalovirus (CMV) and adenovirus infections can cause gland apoptosis. Post-transplant lymphoproliferative disorder should be considered if a Crohn's-like histological picture is seen, and granulomas in biopsies from umbilical cord blood recipients should raise a suspicion of cord colitis syndrome. Finally, the GI tract may be involved directly or indirectly by the disease that originally required haematopoietic stem cell or liver transplantation.

Cytomegalovirus colitis in intensive care unit patients: difficulties in clinical diagnosis

PURPOSE

Cytomegalovirus (CMV) infection occurs increasingly in critically ill patients in intensive care units (ICUs). We reported CMV colitis which has rarely been recognized in the ICU patients.

METHODS

CMV DNA was detected by polymerase chain reaction (PCR) for blood and/or stool samples. Definite diagnosis of CMV colitis required histopathology or CMV immunohistochemical staining of colorectal biopsies. We reviewed ICU patients characterized by positive blood or stool CMV-PCR with colorectal bleeding or water diarrhea.

RESULTS

We identified 18 patients (biopsy-proved, n=8; probable cases, n=10). The most common comorbidities were chronic renal disease, diabetes mellitus, and coronary artery disease. Stool CMV-PCR was positive in 7 of 10 patients (2 of 3 biopsy-proved and 5 of 7 probable cases). Colonoscopy was performed for 15 patients, revealing ulcerative or polypoid lesions. The endoscopists obtained colonic biopsies from 9 patients. Yet, the pathologists reported CMV colitis for 4 patients. Additional 4 patients were confirmed using immunohistochemical stain by the request of clinical physicians. Pseudomembranous colitis was found in 4 patients.

CONCLUSION

Diagnosis of CMV colitis seems difficult in clinical practice and need persistent communication between clinicians. The positive stool CMV-PCR result was a useful hint for adding immunohistochemical stain in mucosal biopsies to make a definite diagnosis of CMV colitis.

Juvenile-like (inflammatory/hyperplastic) mucosal polyps of the gastrointestinal tract in neurofibromatosis type 1

AIMS

Diffuse neurofibromatosis/ganglioneuromatosis, solitary/plexiform neurofibroma, periampullary carcinoids and gastrointestinal stromal tumour (GIST) are the main gastrointestinal manifestations of neurofibromatosis type 1 (NF-1, von Recklinghausen disease). Inflammatory (juvenile-like) polyps have not been recognised to date as specific gastrointestinal (GI) manifestations of NF-1.

METHODS AND RESULTS

We describe four males aged 23-65 years with NF-1 and inflammatory (juvenile-like) gastrointestinal polyps, and review the literature for similar cases. Two patients had single polyps (sigmoid colon and antrum, respectively), one had two polyps (left colon), and one had three polyps (distal oesophagus and colon). Histological appearances were variable, ranging from juvenile-like to granulation tissue-rich, predominantly inflammatory and hyperplastic. Three lesions showed obliterative vasculopathic changes. None had neurofibromatous or ganglioneuromatous polyps. A review of the literature disclosed 11 similar cases. Most patients presented with severe gastrointestinal symptoms and/or anaemia.

CONCLUSIONS

NF-1-associated inflammatory polyps probably represent specific GI manifestations of this disorder, and should be considered, particularly in patients with GI symptoms. They should be distinguished from inflammatory fibroid polyps and from juvenile-like changes associated with ganglioneuroma/ganglioneuromatosis and neurofibroma/neurofibromatosis. Their aetiology remains obscure, but different mechanisms, including NF-1 inactivation, NF-1-associated vasculopathy, and localised mucosal prolapse/damage caused by motility disorders, might be involved.

Atypical presentation of cytomegalovirus infection in a liver transplant patient

Cytomegalovirus (CMV) is the most common viral infection in solid organ transplant recipients. Symptomatic infection usually presents with fever, pneumonia, colitis, or cytopenia. We describe a case of symptomatic CMV infection in a liver transplant recipient presenting with atypical symptoms of only persistent nausea and vomiting, in the absence of classical symptoms and signs; thus, highlighting the importance of high index of suspicion of CMV in immunocompromised patients, keeping in mind the high morbidity and mortality associated with this disease.