Cytomegalovirus Duodenitis Research Articles

Cytomegalovirus Graft Duodenitis Diagnosed by Transanal Double-Balloon Endoscopy Technique in an Enteric-Drained Pancreas Transplant Recipient: A Case Report

Duodenal graft complications are not uncommon after pancreas transplant (PTx). Although direct visualization and biopsy of the duodenal graft are important for accurate diagnosis and management, endoscopic access is often limited in cases of enteric-drained PTx. Herein, we present a case of cytomegalovirus (CMV) graft duodenitis that was successfully diagnosed by transanal endoscopy using the double-balloon technique. The patient was a 54-year-old woman who underwent simultaneous pancreas and kidney transplant for type 1 diabetes mellitus and end-stage kidney disease. Enteric drainage was established by anastomosing the graft duodenum to her ileum. One month after the transplant, she developed fever and complained of lower abdominal pain. Graft duodenitis was suspected by laboratory test and imaging study results. Transanal double-balloon endoscopy was performed, and the biopsy specimen of the mucosa of the graft duodenum revealed CMV duodenitis without histopathologic findings of acute rejection. The postendoscopy course was uneventful. Treatment with ganciclovir was promptly initiated, and the CMV duodenitis was resolved with good function of the pancreas graft. In patients who undergo PTx with establishment of exocrine drainage by enteroanastomosis to the recipient ileum, transanal double-balloon endoscopy might be a feasible and safe technique for the surveillance of duodenal graft complications, including CMV duodenitis.

S3073 A Rare Cause of Repeat Hemorrhage: When Cytomegalovirus Hides in the Small Bowel

Introduction: Cytomegalovirus (CMV) is an opportunistic infection typically seen in immunocompromised patients, like those with Human Immunodeficiency Virus (HIV) or organ and stem cell transplant recipients. CMV infections are exceedingly uncommon in the immunocompetent duodenum. We describe such a case, confirmed with biopsy and complicated by severe repeated gastrointestinal hemorrhage. Case Description/Methods: A 74-year-old male with PMH of diabetes, bladder cancer (status-post resection and ureteral stent placement), presented to the ED with general malaise. Was found to meet sepsis criteria and was anemic with bright red blood on rectal exam. CT abdomen and pelvis revealed multiple pelvic abscesses and free air. Stool testing was positive for C. diff and oral vancomycin and IV zosyn were started. Patient was admitted to telemetry and required 3 separate units pRBC for persistent anemia. CTA abdomen performed on day 3 revealed a duodenal bleed. IR performed an embolization, however, patient remained unstable and required intubation and pressors. Anemia continued to worsen, and patient received an additional 2 units pRBC. GI performed a bedside EGD revealing a large clot and duodenal ulcer. Sepsis continued to worsen, and antibiotics were broadened to meropenem and vancomycin. Anemia continued to worsen, and an additional EGD was performed with source control reported. Patient was extubated, and shortly thereafter, had melena, so a final EGD was performed, identifying friable mucosa and a bleeding duodenal vessel. Hemospray and a clip were deployed to contain bleeding, and the patient received a seventh unit of blood. Biopsied duodenal tissue stain showed CMV (Figure 1A) and histology revealed inclusions (Figure 1B), so ganciclovir was started. Recurrent bleeding subsequently resolved, and patient was discharged to subacute rehabilitation to complete a course of IV ganciclovir. Discussion: Though rare in immunocompetent patients, CMV infections should be considered in severe or persistent gastrointestinal bleeds. CMV duodenitis, while very uncommon, has been documented in case reports and is associated with ischemia and massive hemorrhage. In this case, the patient ultimately required seven units of blood, intubation, and numerous endoscopic procedures as a result of CMV duodenitis. Clinical improvement was seen only once the underlying infection was treated and illustrates the need to consider CMV infection in the differential for recurrent gastrointestinal bleeding.Figure 1.: A: Immunohistochemical stain of tissue from duodenal biopsy identifying CMV. B: Histology of duodenal tissue biopsy under high power showing CMV inclusions.

2538 Severe Protein-Losing Enteropathy and CMV Duodenitis in an Immunocompetent Male

INTRODUCTION: Cytomegalovirus (CMV) infection, typically associated with immunodeficiency, has been reported to also occur in immunocompetent patients. CMV infection of the gastrointestinal (GI) tract is uncommon in immunocompetent hosts and typically involves the lower GI tract. We encountered a case of CMV duodenitis associated with severe protein-losing enteropathy in an otherwise healthy male. CASE DESCRIPTION/METHODS: A 27-year-old man with a 2-year history of mild, intermittent non-bloody diarrhea presented with 2 weeks of worsening diarrhea, epigastric pain, nausea, vomiting and poor oral tolerance. His only medication was emtricitabine/tenofovir for HIV pre-exposure prophylaxis, initiated 4 months prior to presentation. Physical examination revealed a tender epigastrium and anasarca. Laboratory evaluation showed WBC 13.2 K/mcL (12.2% monocytes), albumin 1.9 g/dL, AST 64 U/L, ALT 77 U/L, total bilirubin 1.0 mg/dL, INR 1.0, and lipase 346 U/L. Serum HIV antigen/antibody was negative, and CD4 cell count was 873 cells/mcL. Urinalysis was unremarkable and was without proteinuria. Stool studies were negative for common enteric bacterial pathogens, Clostridium difficile, Giardia, and ova/parasites. Fecal calprotectin was elevated at 390 µg/g. MRI/MRCP imaging of the abdomen and pelvis showed a thickened duodenum, and peripancreatic fat stranding and fluid (suggestive of acute pancreatitis), without biliary or pancreatic duct dilation. EGD showed severe duodenitis with diffuse erythema, mucosal denudation, patchy erosions, and nonbleeding ulcerations. Biopsy with immunostain revealed CMV duodenitis. Serum CMV DNA was mildly elevated at 142 IU/mL. Following multidisciplinary discussion, supportive care was provided without antiviral therapy. Over the next month, the patient improved clinically, with normalization of serum albumin, transaminases, and CMV titer. DISCUSSION: Several reports have described tissue invasive CMV infection in immunocompetent patients, primarily involving the colon. CMV duodenitis and pancreatitis are rare, even in immunocompromised patients. Our case describes a healthy man with severe CMV duodenitis resulting in protein-losing enteropathy. CMV likely caused mild acute pancreatitis in our patient as well. A recent systematic review did not support antiviral therapy for immunocompetent patients with CMV. Supportive care with close monitoring may be sufficient; however, further investigation is needed to routinely support this practice.

Cytomegalovirus duodenitis in immunocompetent patients: what else should we look for?

Cytomegalovirus (CMV) infection is a well-recognised complication of immunodeficiency, although the burden of CMV disease in immunocompetent adults is still unknown. We present the case of a 54-year-old male patient...

Treatment and management of CMV duodenitis in a patient with temporal arteritis

An elderly female, with a definitive diagnosis of temporal arteritis which was under treatment, referred to our hospital with weakness, epigastric pain along with oral ulcerations. Before admission, the patient had developed right sided throbbing headache along with decrease in vision of her right eye with an ESR of 72 mm/h. She was diagnosed as having temporal arteritis and was administered steroids and azathioprine. After a couple of months, patient started having generalized weakness, epigastric pain and oral ulceration and then her intake of solid food decreased. Patient was kept on liquid diet that was delivered by a nasogastric tube. Upper GI endoscopy along with biopsy revealed cytomegalovirus (CMV) duodenitis. She was started on oral ganciclovir and later her symptoms improved. Key point Our case shows that those patients on immunosuppressive therapy who developed GI symptoms should be evaluated for CMV infections. Citation: Majid Z, Ahmed S, Yaseen RT, Shahab R, Mubarak M. Treatment and management of CMV duodenitis in a patient with temporal arteritis Immunopathol Persa. 2018;4(1):e02. DOI: 10.15171/ipp.2018.02.

Cytomegalovirus duodenitis associated with acquired immunodeficiency syndrome

Digestive EndoscopyVolume 25, Issue 3 p. 337-338 Letters, Techniques and Images Cytomegalovirus duodenitis associated with acquired immunodeficiency syndrome Shinya Sugimoto, Shinya Sugimoto Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Yokohama, JapanSearch for more papers by this authorYukihiro Yoshimura, Yukihiro Yoshimura Department of Infectious Disease, Yokohama Municipal Citizen's Hospital, Yokohama, JapanSearch for more papers by this authorHirokazu Komatsu, Hirokazu Komatsu Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Yokohama, JapanSearch for more papers by this author Shinya Sugimoto, Shinya Sugimoto Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Yokohama, JapanSearch for more papers by this authorYukihiro Yoshimura, Yukihiro Yoshimura Department of Infectious Disease, Yokohama Municipal Citizen's Hospital, Yokohama, JapanSearch for more papers by this authorHirokazu Komatsu, Hirokazu Komatsu Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Yokohama, JapanSearch for more papers by this author First published: 25 January 2013 https://doi.org/10.1111/den.12027Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume25, Issue3May 2013Pages 337-338 RelatedInformation

Cytomegalovirus duodenitis, pseudotumour and cholangiopathy in advanced HIV

Gastro-intestinal cytomegalovirus (CMV) infection manifests as oesophagitis, gastritis, enteritis and colitis. Reports of duodenal involvement are rare. We found only one reported CMV-induced pseudotumour of the duodenum and 14 CMV-induced gastrointestinal pseudotumours.

Duodenal segment complications in vascularized pancreas transplantation

Bladder drainage by the duodenal segment (DS) technique is currently the preferred method of pancreas transplantation (PTX) but is associated with unique complications. Over a 7-year period, 191 diabetic patients underwent 201 whole-organ PTXs with bladder drainage using a 6 to 8 cm length of DS as an exocrine conduit. A retrospective chart review was performed to document all DS morbidity. DS complications occurred in 38 cases (19%). Twelve patients developed DS leaks and required operative repair. DS bleeding was documented in 26 cases, necessitating cystoscopy in 22 patients and open repair in eight patients for significant hematuria. Cytomegalovirus (CMV) duodenitis was diagnosed in seven cases, with four presenting as DS leaks and three with hematuria. Five patients experienced ampullary obstruction early after PTX. Rejection of the DS was confirmed by biopsy in 13 patients, including eight cases of acute and five cases of chronic rejection. Two patients had stone formation from the DS staple line. Enteric conversion was performed in five patients for DS abnormalities (leaks in 2 cases, bleeding in 2, and CMV duodenitis in 1). Among patients with DS complications, patient survival is 84% and pancreas graft survival is 68% after a mean follow-up of 44 ± 12 months. Complications related to the DS remain an important source of morbidity but rarely cause death after PTX. In spite of unique side effects, transplantation of the DS remains an acceptable alternative for exocrine drainage after PTX.

Conversion of Exocrine Secretions From Bladder to Enteric Drainage in Recipients of Whole Pancreaticoduodenal Transplants

Between September 1984 and August 1991, 265 whole pancreaticoduodenal transplants were done at our institution, with bladder drainage of exocrine secretions through a duodenocystostomy. Seventeen patients subsequently underwent conversion from bladder to enteric drainage at 2 to 64 months after transplant. Eight conversion procedures were done to correct chronic intractable metabolic acidosis due to bicarbonate loss from the allograft: seven to alleviate severe dysuria, presumed secondary to the action of graft enzymes on uroepithelium; one to prevent recurrent allograft pancreatitis, presumed secondary to back pressure from the bladder; and one because of graft duodenectomy for severe cytomegalovirus duodenitis with perforation. None were done to correct technical complications from the initial transplant operation. The conversions were done by dividing the graft duodenocystostomy, then re-establishing drainage through a graft duodenal-recipient jejunal anastomosis. A simple loop of recipient jejunum was used for the duodenojejunostomy in 15 cases, and a Roux limb in two. One of those two cases had a previously created Roux limb that was available for use. The other was in the patient who underwent graft duodenectomy and subsequent mucosa-to-mucosa anastomosis of the pancreatic duct to a newly created Roux limb of jejunum. All patients experienced relief of their symptoms after operation. Two patients had surgical complications (12%), an enterotomy in one case, which was closed operatively, and an enterocutaneous fistula in the other case, which healed spontaneously with bowel rest and parenteral nutrition. The drawback to conversion is loss of urine amylase as a marker for rejection, particularly in recipients of solitary pancreas grafts (n = 5). In recipients of simultaneous pancreas-kidney (SPK) allografts (n = 12), the kidney can still be used to monitor for rejection (two with follow-up < 1 year, 10 with follow-up > 1 year). None of our solitary pancreas recipients, however, have lost graft function (follow-up, 10 to 36 months). The only pancreas allograft loss was in an SPK recipient who also rejected the kidney 6 months after conversion. She received a second SPK transplant with enteric drainage, and is insulin independent and normoglycemic 10 months after retransplantation. Patients converted for metabolic acidosis tended to have impaired renal function (mean creatinine, 2.14 +/- 0.98 mg/dL at time of conversion) due to chronic rejection, progression of native kidney diabetic nephropathy, or cyclosporine toxicity, and possibly could not compensate for bicarbonate loss from the pancreas allograft.(ABSTRACT TRUNCATED AT 400 WORDS)