Viral Infections in Immunocompetent Patients: A Case Series of HSV and CMV Gastrointestinal Infections

Abstract

Purpose: BACKGROUND: Herpes Simplex virus (HSV) and Cytomegalovirus (CMV) gastrointestinal tract (GIT) infections are seen in immunocompromised hosts. These infections are rare in immunocompetent hosts. We report HSV and CMV infection of the GIT in 6 non-immunocompromised patients. METHODS: Patients diagnosed with either HSV or CMV GI infections between Feb., 2007 and Sept., 2009 by one gastroenterologist at a teaching hospital were included. RESULTS: Two patients had CMV infection; one had CMV esophagitis and one CMV proctitis. The patient with CMV esophagitis was 91 and presented with heme positive stools; the patient with CMV proctitis was 88 and had a complete resection of non-small cell lung cancer followed by a prolonged hospitalization. None of these patients had a known history of immunosuppression. All four cases of HSV GI infection were found to have HSV esophagitis and no known immunosuppression. Two of these patients presented with hematochezia, one with melena, and one with atypical chest pain. All four patients with HSV esophagitis had diabetes mellitus (DM) and coronary artery disease (CAD). Candida esophagitis was seen in two of these patients; one with end stage renal disease and one with COPD requiring inhaled steroids. All patients received appropriate antiviral with good response. DISCUSSION: For CMV infection, the GIT is the most commonly involved system, and colon and rectum are the most commonly reported sites. Phagocytic capacity, synthesis of reactive oxygen intermediates, and intracellular killing efficiency of neutrophils are impaired with aging, and can lead to increased susceptibility to CMV infections. Prolonged hospitalization, critical illness, and extended duration of mechanical ventilation are also among the risk factors for CMV infection. For HSV GIT infections, DM, renal failure and advanced age are described as risk factors for increased mortality. Gastric acid inhibitors, broad spectrum antibiotics, DM and blood dyscrasias can also predispose to HSV and candida esophagitis. Although DM can alter the immune system, it has not been established as a definitive risk factor for HSV infection of the GIT. Antiviral treatment of CMV and HSV infection of the GIT is recommended in patients presenting with severe infections where it shortens the duration of symptoms. CONCLUSION: CMV infection of the GIT should be considered in the elderly and those with prolonged hospitalization presenting with hematemesis and hematochezia. The presence of diabetes mellitus in all four of our patients with HSV esophagitis suggests an association between the two conditions.