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Abstract
Cytomegalovirus (CMV) infection is a common cause of morbidity and mortality among patients receiving chronic maintenance immunosuppression and is often considered the most important infection in renal transplantation. CMV gastritis has been reported in transplant recipients. Symptoms are usually considered nonspecific, and gastroscopy with biopsy is usually performed to establish the diagnosis.
We report a case of primary CMV gastritis in a renal transplant recipient. A 34-year-old man presented 4 months after renal transplantation with a 1-week history of epigastric pain that decreased in supine position, increased while sitting, and further increased when standing or walking. The immunosuppressive regimen consisted of tacrolimus, mycophenolate mofetil, and prednisone. Evaluation revealed CMV viremia with a high viral load and CMV gastritis was confirmed using gastroscopy and histopathologic examination. Intravenous ganciclovir was started and continued for 3 weeks. The epigastric pain completely resolved after treatment with ganciclovir.
Postural epigastric pain as a sign of CMV gastritis is fairly rare in renal transplant recipients. To our knowledge this is the third article presented in the literature so far.
... 1,2 CMV gastritis is of certain importance because of its reported association with postural epigastric pain. [3][4][5] Postural epigastric pain is an uncommon symptom and is hardly acquired unless specifically asked to the patient. It can be described as epigastric pain relieved in supine position, aggravated while sitting, and further increased with standing or walking. ...
... She also had endoscopic biopsy to prove histological CMV gastritis and treated with ganciclovir. 3 More recently Li et al. 5 also reported a 34-year-old renal transplant recipient who presented with postural epigastric pain and was found to have biopsy-proven CMV gastritis. ...
... In conclusion, postural epigastric pain is a rare symptom and it has not been described together with a clinical entity. [3][4][5] Although not proved yet, postural epigastric pain can be regarded as a unique symptom of CMV gastritis. Renal transplant patients presenting with postural epigastric pain which is not relieved with acid suppression should raise suspicion of CMV gastritis and this has to be confirmed by endoscopy and biopsy. ...
Abstract Postural epigastric pain is an uncommon symptom and is hardly acquired unless specifically asked to the patient. Here we present a cytomegalovirus (CMV) gastritis case in a renal transplant patient with postural epigastric pain. A 36-year-old male was admitted to our clinic on the 50th day of renal transplantation with postural epigastric pain. All investigations were unremarkable except biopsy-proven CMV gastritis and increased CMV viral load. The patient was free of symptom after ganciclovir treatment. Postural epigastric pain has not been described together with a clinical entity. Although not proved yet, it can be regarded as a unique symptom of CMV gastritis. Renal transplant patients presenting with postural epigastric pain which is not relieved with acid suppression should raise suspicion of CMV gastritis and this has to be confirmed by endoscopy and biopsy.
... The colon and stomach are the most common sites of its gastroin testinal infection. Although postural epigastric pain has been described as a sign of CMV gastritis [2] , symptoms of ...
... The colon and stomach are the most common sites of its gastroin testinal infection. Although postural epigastric pain has been described as a sign of CMV gastritis [2] , symptoms of this disorder are usually nonspecific and include epigastric pain, fever, nausea and bleeding. Endoscopic features are quite variable and include macroscopically normal mucosa, diffuse erythema, nodules, pseudotumors, erosions and ulcers. ...
Cytomegalovirus (CMV) has been increasingly recognized as an important common pathogen in an immunocompromised state. The colon and stomach are the most common sites of its gastrointestinal infection. Symptoms of CMV gastritis are usually nonspecific and include epigastric pain, fever, nausea and bleeding. Endoscopic features are quite variable and include macroscopically normal mucosa, diffuse erythema, nodules, pseudotumors, erosions and ulcers. The bioptic detection of intranuclear inclusions is the hallmark of CMV infection. Most gastrointestinal CMV infection responds well to ganciclovir. We present endoscopic and histopathological features of CMV gastritis in a 71 year old woman receiving long-term prednisolone for pemphigus vulgaris.
... 2,3 Manifestations are nonspecific and include fever, epigastric discomfort, anorexia, nausea, vomiting, constipation, diarrhea, and a skin rash. 2,12,13 Although our patient was immunocompetent, his infection did not remain clinically insignificant. He presented with severe sharp epigastric pain radiating to the right upper and lower quadrants associated with nonbilious nonprojectile nonbloody vomitus, nonbloody nonmucoid watery diarrhea, and reduced oral intake. ...
Cytomegalovirus (CMV) belongs to the Herpesviridae family, and it is considered the largest virus to infect humans. Primary CMV infection frequently targets immunodeficient patients and is often symptomatic. However, it may remain latent or clinically unapparent for years in immunocompetent individuals. CMV infection rarely presents as an invasive disease in the latter group of individuals, in which case, the most common site of involvement in the gastrointestinal tract. When CMV affects the gastrointestinal tract, the colon and stomach are the 2 frequently involved sites. This case report describes a unique case of an immunocompetent patient who presented with acute excruciating periumbilical pain and was diagnosed with acute gastritis secondary to CMV infection and possible Helicobacter pylori –associated chronic active gastritis. Symptoms resolved entirely soon after treatment with antimicrobials that cover for both infections. The diagnosis was based on histopathologic findings from biopsies taken from the stomach during the endoscopic evaluation combined with positive CMV serology and positive CMV-deoxyribonucleic acid.
... The most common reported sites of involvement in CMV gastritis are antrum, [11,13] fundus [14] and distal stomach [15]. The endoscopic patterns of CMV gastritis are variable, and include diffuse erythema, erosions, nodules, plaques, and ulcerations [16,17]. In our patient, endoscopy revealed multiple erosions noted in the gastric body and antrum. ...
Cytomegalovirus (CMV) can cause wide spectrum of the diseases with large bowel been most commonly affected. However, it rarely effects the upper part of the alimentary canal including the esophagus and stomach. Here, we present to you a case of renal transplanted recipient with a post-transplant history of non-Hodgkin lymphoma evaluated for dyspepsia and was diagnosed to have CMV gastritis on histopathology.
... [219][220][221][222] An unusual but unique, consistent clinical presentation in solid organ transplant patients is postural epigastric pain. [223][224][225][226] On endoscopy, the CMV-infected stomach can show mucosal edema, erythema, congestion, erosions, or ulcers. [227][228][229][230] CMV gastritis can also present with hypertrophic gastric folds, also known as hypertrophic gastropathy, and can resemble Ménétrier disease both endoscopically and microscopically. ...
This manuscript presents a review of infectious causes of gastritis aimed at the practicing anatomic pathologist. We shall highlight unique histologic findings and clinical attributes that will assist those analyzing endoscopically obtained mucosal biopsies of the stomach or resection specimens.
Background
Human‐cytomegalovirus (hCMV) infection involving the gastrointestinal tract represents a leading cause of morbidity and mortality among kidney transplant (KT) recipients (KTRs). Signs and symptoms of the disease are extremely variable. Prompt anti‐viral therapy administration and immunosuppression modification are key factors for optimizing management. However, complex work‐up strategies are generally required to confirm the preliminary diagnosis. Unfortunately, solid evidence and guidelines on this specific topic are not available.
We consequently aimed to summarize current knowledge on post‐KT hCMV‐related gastrointestinal disease (hCMV‐GID).
Methods
We conducted a systematic review (PROSPERO ID: CRD42023399363) about hCMV‐GID in KTRs.
Results
Our systematic review includes 52 case‐reports and ten case‐series, published between 1985 and 2022, collectively reporting 311 cases. The most frequently reported signs and symptoms of hCMV‐GID were abdominal pain, diarrhea, epigastric pain, vomiting, fever, and GI bleeding. Esophagogastroduodenoscopy and colonoscopy were the primary diagnostic techniques. In most cases, the preliminary diagnosis was confirmed by histology. Information on anti‐viral prophylaxis were extremely limited as much as data on induction or maintenance immunosuppression. Treatment included ganciclovir and/or valganciclovir administration. Immunosuppression modification mainly consisted of mycophenolate mofetil or calcineurin inhibitor minimization and withdrawal. In total, 21 deaths were recorded. Renal allograft‐related outcomes were described for 26 patients only. Specifically, reported events were acute kidney injury ( n = 17), transplant failure ( n = 5), allograft rejection ( n = 4), and irreversible allograft dysfunction ( n = 3).
Conclusions
The development of local and national registries is strongly recommended to improve our understanding of hCMV‐GID. Future clinical guidelines should consider the implementation of dedicated diagnostic and treatment strategies.
Cytomegalovirus is an entity which causes significant morbidity and mortality among solid organ transplant patients. It may occur as a primary infection or be reactivated. In either case clinical manifestations vary. We report the case of a patient with severe epigastric pain related to posture which was the primary symptom of a cytomegalovirus infection. © 2015 Asociaciones Colombianas de Gastroenterología, Endoscopia digestiva, Coloproctología y Hepatología.
Abstract
Cytomegalovirus is an entity which causes significant morbidity and mortality among solid organ transplant
patients. It may occur as a primary infection or be reactivated. In either case clinical manifestations vary. We
report the case of a patient with severe epigastric pain related to posture which was the primary symptom of
a cytomegalovirus infection.
Keywords: Cytomegalovirus, renal transplantation, gastritis, epigastric pain.
Resumen
La enfermedad por citomegalovirus es una entidad con importante morbilidad y mortalidad en pacientes
trasplantados de órgano sólido, que se puede presentar como primoinfección o reactivación y con manifestaciones clínicas muy variables. A continuación se reporta el caso de un paciente con dolor epigástrico intenso postural como síntoma inicial de primoinfección por citomegalovirus.
Palabras clave: Citomegalovirus, trasplante renal, gastritis, dolor epigástrico.
Cytomegalovirus (CMV) infection of the gastrointestinal tract is the most common manifestation of tissue-invasive CMV disease, and is a significant cause of morbidity and mortality in the solid organ transplantation (SOT) recipient. In addition to the direct effects of the infection, its indirect effects on allograft function, risk for other opportunistic infections, and mortality are significant in this population. The most common clinical syndromes are esophagitis, colitis, and hepatitis; however, infection can occur anywhere in the gastrointestinal tract. Diagnosis is usually by histopathology or viral culture of tissue specimens; molecular assays also often have a role. Antivirals are the cornerstone of therapy for gastrointestinal tract CMV disease and complications such as recurrent infection and antiviral resistance are not uncommon. Prevention with antiviral prophylaxis or preemptive therapy is important. This review summarizes recent data regarding the clinical manifestations, diagnosis, treatment, and prevention of gastrointestinal tract CMV infection in the SOT population.
• Infection due to cytomegalovirus is a substantial cause of morbidity and mortality in immunocompromised patients. In particular, cytomegalovirus infection has been associated with a significant detrimental effect on patient and allograft survival after solid-organ transplantation. We are evaluating a new antiviral agent, ganciclovir 9-[1,3-dihydroxy-2-2 propoxymethyl] guanine (DHPG), used in solid-organ transplant recipients who developed life-threatening cytomegalovirus infections. Between March 1, 1987, and June 30, 1989, we treated 93 solid-organ transplant patients who developed tissue-invasive cytomegalovirus disease. From this group of patients we have identified 14 patients with primary gastrointestinal cytomegalovirus disease who received treatment with DHPG. Tissue diagnosis was made by endoscopy of the upper gastrointestinal tract (11 patients) or colonoscopy (three patients). Invasive cytomegalovirus disease was identified prior to severe complications of the gastrointestinal tract in all but one patient, who suffered colonic perforation prior to treatment with DHPG and subsequently died of bacterial sepsis. While 13 of the 14 patients improved after treatment with DHPG, four patients required additional treatments for recurrent cytomegalovirus disease and recovered. No DHPG toxicity was observed. We believe treatment with DHPG is indicated in this patient population, but that further studies are indicated to fully define the impact of this recommendation on both patient and allograft survival after solid-organ transplantation.
(Arch Surg. 1991;126:202-206)
As the largest lymphoid organ in the body, the gastrointestinal tract is a potential reservoir for human immunodeficiency virus (HIV), the causative agent of the acquired immunodeficiency syndrome (AIDS), and it is an important site for HIV-induced immunodeficiency. The resulting defects in cellular and humoral defense mechanisms predispose the gastrointestinal tract to a spectrum of viral, fungal, bacterial, and protozoan pathogens that cause relentless morbidity and, in some cases, death. With a thorough diagnostic evaluation, physicians can identify one or more of these pathogens in a majority of patients with AIDS who have gastrointestinal symptoms. The identification of enteric pathogens in patients with AIDS is important because an increasing array of therapeutic regimens is becoming available to treat many of these infections.
Cytomegalovirus (CMV) causes major morbidity in organ transplant recipients. Gastrointestinal disease was the most prominent manifestation of CMV infection in a population of heart and heart-lung transplant patients, with an incidence of 9.9%, compared with pneumonitis (4.0%) and retinitis (0%), and occurred most frequently in CMV-seronegative recipients of organs from CMV-seropositive donors. Clinical manifestations included gastritis (nine patients), gastric ulceration (four patients), duodenitis (three patients), esophagitis (one patient), pyloric perforation (one patient), and colonic hemorrhage (one patient). Patients with gastrointestinal CMV infection were treated with intravenous ganciclovir sodium therapy, 5 mg/kg twice daily, for 2 to 8 weeks, with positive clinical, endoscopic, histologic, and virologic responses. Relapses occurred in four of nine patients who were followed up for a median period of 18 months. Retreatment resulted in healing of endoscopic lesions and in viral clearing. We conclude that early endoscopic evaluation for CMV is indicated in heart and heart-lung transplant patients with gastrointestinal symptoms. This study further suggests that intravenous ganciclovir therapy is effective for the treatment of gastrointestinal CMV in these patients.
Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract can cause serious disease in immunocompromised patients.
Recipients of solid organ and bone marrow transplants, persons with malignancies, and those receiving immunosuppressive medications
are at risk. When CMV infection of the GI tract causes disease, symptoms include pain, ulceration, bleeding, diarrhea, and
perforation. All levels of the GI tract, from the oropharynx to the anus, may be involved. Pathological examination of involved
gut typically reveals diffuse ulcerations and necrosis with scattered CMV inclusions, although a variety of other abnormalities
have been described. Before the introduction of antiviral therapy effective against CMV, mortality was high. However, the
use of ganciclovir or foscarnet has improved the prognosis of CMV disease of the GI tract dramatically. CMV infection should
be included in the differential diagnosis of GI disease in immunocompromised patients, and the clinician should pursue appropriate
diagnostic and therapeutic interventions aggressively.
Cytomegalovirus (CMV) gastritis has been reported in transplant patients. Symptoms are considered nonspecific, and gastroscopy with biopsy is usually performed to establish the diagnosis. Three patients are described here 1 to 3 months after solid organ transplantation, with primary CMV gastritis, confirmed by gastroscopy, histopathologic examination and cultures. The clinical presentation in all three cases was sharp epigastric pain that decreased in a supine position, increased while sitting and further increased when standing or walking. The epigastric pain completely resolved after treatment with ganciclovir. To the best of our knowledge, such postural epigastric pain has not been described as a specific symptom in any other clinical entity and may be a unique sign of primary CMV gastritis.
Cytomegalovirus (CMV) infection is a common cause of morbidity and mortality among patients receiving chronic maintenance immunosuppression and is often considered the most important infection in renal transplantation. CMV gastritis has been reported in transplant patients. We present a case of CMV gastritis with epigastric pain that decreased in supine position, increased while sitting, and further increased when standing or walking. To our knowledge this is the second article presented to the literature so far.