Successful therapy for severe cytomegalovirus gastritis in a diabetic woman

Abstract

Cytomegalovirus (CMV) gastritis is very rare in immunocompetent persons. CMV infection of the gastrointestinal tract is frequent and may be serious in immunocompromised patients.1 Symptoms of CMV gastritis are usually epigastralgia, fever, and bleeding. We report a diabetic patient with diffuse gastritis caused by CMV, which responded significantly to ganciclovir therapy. A 77-year-old woman with diabetes mellitus well under control presented with coffee-ground vomitus for two days on November 5, 2013. The patient did not receive prior blood transfusion and steroid use. Laboratory data included a white blood cell count of 16 300/μL; hemoglobin, 10.8 g/dL; platelet count, 219 000/μL; and creatinine, 1.24 mg/dL. Upper endoscopy showed reflux esophagitis and diffuse gastric ulcers (Figure 1A). Mucosal biopsy of the stomach showed chronic active gastritis with necrosis. Helicobacter pylori microorganisms and anticytokeratin antibodies (AE1/AE3) were not identified. Intravenous pantoprazole followed by oral lansoprazole therapy was given. However, severe episodes of gastric bleeding recurred. A computed tomography scan revealed severe gastric wall thickening without lymphadenopathy or tumor in the abdomen (Figure 1B). She was transferred to intensive care unit for aspiration pneumonia with septic shock. Intravenous pantoprazole was reused. Norepinephrine, antibiotic imipenem, and low-dose hydrocortisone (200 mg/day × 1 day, 100 mg/day × 6 days) were given for septic shock. On December 9, CMV–polymerase chain reaction (PCR) tests were performed for gastric juice and blood sample, results of which were positive. CMV antigenemia revealed two positive cells per 200 000 polymorphonuclear cells. Human immunodeficiency virus (HIV) antibody was found to be negative. Blood carcinoembryonic antigen was 4.0 ng/mL. Follow-up endoscopy still showed diffuse gastric ulcers with nodules (Figure 1C), but immunohistochemical staining for CMV on mucosal biopsy was positive. Ganciclovir was given intravenously, and thereby gastric bleeding improved. Ganciclovir was continued for three weeks until negative result on CMV–PCR testing for gastric juice on January 9, 2014. Subsequent oral valganciclovir was maintained for four weeks. On January 16, follow-up endoscopy showed improving gastric ulcers (Figure 1D) and negative CMV immunostaining. The patient was discharged uneventfully on February 12, 2014. CMV is a virus that infects both healthy and compromised hosts. In healthy hosts, CMV most often manifests as an infectious mononucleosis-like illness. In immunocompromised hosts, CMV often presents as pneumonitis, retinitis, hepatitis, or colitis.2 CMV gastritis is seen almost exclusively in HIV-infected and posttransplantation patients.3, 4 CMV gastritis in immunocompetent hosts is quite rare but is particularly challenging. Endoscopic features are quite variable and include macroscopically normal mucosa, diffuse erythema, nodules, pseudotumors, erosions, and ulcers. Definite diagnosis is based on endoscopic gastric biopsy, especially with specific CMV immunostaining.5 In the present case, we found positive result on CMV–PCR testing for gastric juice, which may be a useful screening tool for rapid diagnosis of CMV gastritis. We successfully adapted negative conversion CMV–PCR testing for gastric juice as an aide for therapeutic guide to shift intravenous ganciclovir to oral valganciclovir in subsequent therapy. Possibly, early detection and treatment for CMV gastritis could shorten the duration of bleeding symptoms and hospital stay. Although the diffuse gastric ulcers occurred before the hydrocortisone use, we could not exclude the possibility that hydrocortisone might aggravate the CMV disease. In conclusion, CMV gastritis manifesting as acute upper gastrointestinal bleeding may occur in immunocompetent hosts. Although not commonly seen in bleeding gastritis, CMV should be considered among patients with diffuse ulcerative gastritis and thus prolonged antiviral therapy is needed. CMV–PCR testing for gastric juice could be a diagnostic tool before biopsies are made available. The above study has been granted exemption from review by the Institutional Review Board of Chi-Mei Medical Center (application no. 10412-E02).