Nisan 2015

18-21

A WOOLS ¹ , Halil AKOL ²

¹ Faculty of Medicine, University of Utrecht, The Netherlands ² Gastric-enterologist, Meander Medical Centre, The Netherlands

Sitomegalovirüs, bazı durumlarda morbidite ve mortalite ile önemli gastrointestinal manifestasyonlar gibi bazı organ spesifik enfeksiyonlara yol açan yaygın bir viral patojendir. Immün sistemi sağlam bir konakçıda sitomegalovirüs enfeksiyonu nadirdir. Biz burada biyopsiler ve seroloji ile üst gastrointestinal endoskopide tanı konulan 54 yaşındaki bir hastada sitomegalovirüs gastrit olgusunu sunuyoruz.

CMV, gastritis

The infection caused by cytomegalovirus (CMV) is diverse and depends greatly on the host. It is a common infection in immunocompetent hosts but is generally asymptomatic, or may present with a mononucleosis-like syndrome of fever, lymphadenopathy and pharyngitis. The prevalence of CMV infection ranges from 40 to 100% of the adult population (1). An uncommon manifestation of CMV is organ specific, which can involve the gastrointestinal system. CMV infections in immunocompromised hosts such as those with human immunodeficiency virus (HIV), malignancy, or organ transplantation, can lead to substantial morbidity and mortality. Literature reports on the occurrence of organ specific CMV infection is limited however, to small series and case reports. (2) CMV infection in the stomach can lead to gastric ulcers that are difficult to differentiate from Helicobacter pylori-or non-steroidal anti-inflammatory drug-related ulcers; characteristic morphological features specific to CMV, immunohistological detection of CMV and polymerase chain reaction (PCR) amplification detection of CMV DNA may help differentiate between the two. (3) Further, it is further unclear if and when antiviral therapy is indicated. A recent study suggest that antiviral therapy such as ganciclovir should be considered in immune-incompetent patients and in immunocompetent patients who are male, age 55 years or older, and those with chronic disease. (4) In this case report we describe an immunocompetent adult who presented with epigastric pain and weight loss. An upper gastrointestinal endoscopic examination revealed gastritis. Biopsies showed viral inclusion bodies characteristic of CMV.

Although CMV infections in the gastrointestinal tract of im-munocompromised individuals have been reported with inc-reasing frequency in recent years, there have been only a few reports of CMV infections in the gastrointestinal tract of im-munocompetent individuals. We report a case of CMV gastri-tis in an immunocompetent patient. We continue to evaluate the patient’s immuno-status; thus far no abnormalities have been found. The relationship between symptomatic ulcer disease with the finding of CMV inclusions in mucosal biopsies of ulcers is unclear. It is unknown whether CMV is a primary cause of gastrointestinal lesions or whether CMV colonizes pre-existing lesions. We needed to distinguish the gastric lesions in the present case from linitis plastic and primary gastric lymphoma, as it needed further evaluation and treatment. We diagnosed the gastric lesions as CMV gastritis due to the specific histological findings, serological markers and PCR. The endoscopic fin-dings of CMV gastritis are not different from other etiologies such as NSAID’s and Helicobacter pylori. Therefore, the di-agnosis of CMV gastritis is primarily based on the histological finding of inclusion bodies characteristic for CMV infection. Furthermore, the number of inclusion bodies found does not correlate with the severity of inflammation in the gastrointes-tinal tract (5). It is sometimes speculated that the CMV infection that is found has no direct effect on the lesions, and is defined as a co-localized. However, in this case, the patient’s symp-toms disappeared after treatment and follow-up endoscopy showed healing of the ulceration. Subsequently the stomach biopsies did not show inclusion bodies after treatment. From these findings, we reached the conclusion that CMV infection itself contributed to the formation of gastric ulcerations. CMV is usually asymptomatic or seen as a mononucleosis sy-ndrome and self-limiting. CMV is a unique disease that rarely causes gastrointestinal involvement in immunocompetent patients. This case demonstrates that CMV should be taken into account when diagnosing patients with gastritis. Since it is uncommon in immunocompetent hosts, an attempt should be made to exclude immunodeficiency. Furthermore, a con-servative approach, avoiding anti-viral medications, can be effective.

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4. Fyock C, Gaitanis M, Gao J, et al. Gastrointestinal CMV in an elderly, immunocompetent patient. R I Med J 2014;97:53-6.
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