Viral Gastritis in Granulomatosis with Polyangiitis

Abstract

Purpose: A 62-year-old Hispanic female with past medical history of granulomatosis with polyangiitis (Wegener's) was evaluated for chronic anemia. Review of symptoms was negative for diarrhea, nausea, vomiting, abdominal pain, melena or hematochezia. Her medications included prednisone 20 mg and cyclophosphamide 50 mg. Physical exam was remarkable for pallor, normal oropharynx and negative for lymphadenopathy. Abdomen was soft, non-tender, non-distended, with normal bowel sounds. Pertinent laboratory data included hemoglobin (7.9 g/dL), and serum albumin 3.1 gm/dL. Iron studies were consistent with anemia of chronic disease. Colonoscopy was significant only for diverticulosis. Esophagogastroduodenoscopy (EGD) revealed multiple erosions in the gastric antrum along with small non-bleeding clean based ulcer (Forrest class III). Biopsy of the gastric antrum showed intra-nuclear inclusions bodies (“owl's eye”) with positive immune staining for Cytomegalovirus (CMV) antigen, pathognomonic for CMV gastritis. Patient received intravenous ganciclovir treatment for one week followed by one week of oral valganciclovir, which was curative as confirmed by negative CMV serology. There have been reported cases of symptomatic CMV gastritis. However, we present a rare case of CMV gastritis in an asymptomatic patient with history of granulomatosis with polyangiitis. Symptoms usually include nausea, vomiting, dysphagia, odynophagia, abdominal pain, tenesmus and hematochezia. It frequently affects immune-compromised patients with Human Immunodeficiency Virus, malignancy, organ transplant recipients, those on immunosuppressive medications or long standing steroid therapy. CMV infection of the gastrointestinal tract commonly involves the esophagus, stomach and colon. The endoscopic findings of CMV infection are variable from simple erosion, ulceration to pseudo-tumor formation. In patients with persistent immune deficiency such as granulomatosis with polyangiitis, endoscopic evaluation is a reasonable approach to prevent potential serious complications such as gastrointestinal hemorrhage, progressive intestinal disease and death.Figure