Cytomegalovirus Gastritis in Renal Graft: Case Report

AUTHORS

Farahnaz Noroozinia 1 , Sedra Mohammadi 2 , * , Sina Dindarian ORCID 2 , Hozan Mohammadi 3

1 Department of Pathology, Urmia University of Medical Sciences, Urmia, IR Iran

2 Student Research Committee, Urmia University of Medical Sciences, Urmia, IR Iran

3 Student Research Committee, Tabriz University of Medical Sciences, Tabriz, IR Iran

How to Cite: Noroozinia F, Mohammadi S, Dindarian S, Mohammadi H. Cytomegalovirus Gastritis in Renal Graft: Case Report, Iran Red Crescent Med J. 2018 ; 20(1):e66026. doi: 10.5812/ircmj.66026.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 20 (1); e66026
Published Online: January 21, 2018
Article Type: Case Report
Received: December 31, 2016
Revised: March 29, 2017
Accepted: October 23, 2017
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Abstract

Introduction: Cytomegalovirus (CMV) is an important pathogen, and its infection develops in 70% to 90% of transplant patients. Upper gastrointestinal (GI) symptoms in the solid organ recipient are common (20%) and clinical signs are more serious in 10% of cases.

Case Presentation: This study reports on a 30-year-old male with end-stage renal disease that had undergone kidney transplantation from a CMV negative donor at Imam Khomeini hospital, Urmia, Iran during June 2013. After 1.5 months, he was admitted with fever, generalized body pain, oral aphthous ulcers, and epigastric pain accompanied by malaise. Endoscopic examination and clinicopathological investigations revealed multiple antral erosions with surrounding erythema.

Management and Outcome: The patient was started on Intravenous (IV) ganciclovir 5mg/kg per day, every 12 hours initially for 3 weeks. Afterwards, the general condition of the patient improved.

Discussion: The colon and stomach were the most common sites of the gastrointestinal infection, yet localization to the gastric antrum is not common.

Keywords

Cytomegalovirus (CMV) Renal Transplantation Gastritis Infection

Copyright © 2018, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Introduction

Cytomegalovirus (CMV) is a Herpes virus family member and also a common cause of infection in immunocompromised hosts, including patients with acquired immune deficiency syndrome (HIV/AIDS), neonates, and transplant recipients (1). Overall, 50% to 90% of American and European adults have CMV infection (2, 3). The virus remains latent during life and it is characterized by its ability to become reactivate periodically (4, 5). In solid organ transplantation, common sites of gastrointestinal (GI) infection are colon and stomach, yet infection of the stomach with antral involvement is rare (6). Cytomegalovirus is the main reason of morbidity in immunocompromised patients’ upper GI (7, 8). Patients with CMV gastritis have nonspecific symptoms, including epigastric pain, nausea, vomiting, high-grade fever, and GI bleeding (9). Endoscopic features are quite variable and include normal mucosa, diffuse erythema, nodules, pseudo-tumors, and erosions yet characteristic findings on upper endoscopy are punched-out gastric ulcers (10). Most CMV gastrointestinal infections respond well to Ganciclovir (11). This report describes a renal transplant recipient with dyspeptic complains presentation, whose principal sign was multiple antral erosions, which have rarely been reported so far.

2. Case Report

A 30-year-old male with end-stage renal disease underwent kidney transplantation from a CMV negative donor at Imam Khomeini Hospital, Urmia, Iran in June 2013. Serologic determination for CMV IgM and IgG antibodies were done before transplantation and both antibodies were negative. The patient received an induction therapy of anti-thymocyte globulin (ATG) for 14 days, Ganciclovir for 21 days, and Methyl-prednisolone for 3 days. Renal function improved, and the postoperative was uneventful. Patient was discharged on day 15. One and a half months later, he presented fever, generalized body pain, oral aphthous ulcers, and epigastric pain accompanied by malaise. Clinical examination revealed epigastric tenderness. The laboratory findings were as following: hemoglobin: 10.5 mg/dL (Nl: 43-51), white blood count (WBC): 7100 (Nl: 4,000 - 10,000), Platelet: 38000 (Nl: 150,000 - 400,000). Liver enzyme tests and serum amylase levels were normal. Blood, urine and stool cultures were negative. Tests for CMV antigen and anti-CMV antibody (IgM) were positive. The abdominal-pelvic ultrasonography was normal. The upper gastrointestinal endoscopic revealed multiple antral erosions with erythema, yet no deep ulcer was seen. Histopathological examination of lesions showed large epithelial cells with intranuclear inclusion body called Owl’s eye appearance, which is highly specific for CMV infection (Figure 1A and 1B). No evidence of Helicobacter pylori infection was seen. The patient was started on Ganciclovir IV 5mg/kg/day every 12 hours, initially for 3 weeks. The fever subsided afterwards; blood cell count returns to normal ranges and clinical status improved (Table 1).

Photomicrography of the gastric biopsy showing in A, Large epithelial cells with eosinophilic intranuclear inclusions (x10 H&E), in B, Large epithelial cells with characteristic owls’ eye eosinophilic intranuclear inclusion body surrounded by a clear halo (x 40 H&E).
Figure 1. Photomicrography of the gastric biopsy showing in A, Large epithelial cells with eosinophilic intranuclear inclusions (x10 H&E), in B, Large epithelial cells with characteristic owls’ eye eosinophilic intranuclear inclusion body surrounded by a clear halo (x 40 H&E).
Table 1. Paraclinical Test Results of the Patientsa
Hemoglobin, mg/dLWBCPlateletLiver Enzyme Tests and Serum Amylase LevelsBlood, Urine and Stool culturesHelicobacter Pylori Infectionabdominal-Pelvic UltrasonographyCMV Antigen and Anti-CMV antibody (IgM)
Results10.57,10038,000NormalNegativeNegativeNormalPositive

aThe results of complete blood count (CBC), liver function tests, and abdominal pelvic ultrasonography were normal. Blood, urine, and stool cultures and H. pylori test results were negative. Both CMV antigen and anti-CMV antibody test results were positive.

3. Discussion

Infection with CMV develops in 70% to 90% of the transplant patients (6). Some of these infections represent a reactivation of the latent virus, while some may be primary infection transmitted from a donor to the recipient (12). One of the most important sites of latent infection is the GI tract. The CMV infection of GI tract occurs within the 6th and 12th months after the transplantation depending on the type of transplantation and the serologic status of the donor and recipient. The colon and stomach are common sites of gastrointestinal infection. The rate of GI involvement by CMV is high and gastric CMV infections are usually located in the fundus with adjacent involvement of the gastro-esophageal junction, and the gastric antrum is not common (6). However, in the study of Gupta et al. (6), all five reported patients had lesions in the antrum (6). Symptoms of CMV gastritis are nonspecific, including epigastric pain, nausea, vomiting, fever, and bleeding (9). There are only a few references in the literature to postural epigastric pain as a symptom of CMV gastritis (13, 14). Although endoscopic features are variable, frequent endoscopic findings in patients with gastric involvement by CMV are punched out gastric ulceration or mild erosion. The ulcer base is the site of most intense inflammations. These histologic alterations may be patchy, therefore 8 to 10 biopsies of suspicious lesions are recommended (6, 13). Pyloric stenosis, bleeding, and perforation are all potential complications of CMV gastritis. It has been suggested that there is an association between the use of Mycophenolate mofetil and citomegalovirosis, especially in the GI tract (15). Treatment of an active disease includes reduction in the immunosuppressive regimen, and administration of intravenous Ganciclovir. Remission occurs in the majority of the patients with one course of treatment. However, an additional period of treatment is not infrequent. Cytomegalovirus antigenemia and clinical symptoms resolved in the patient with a course of 21 days of Ganciclovir IV 5mg/kg/day treatment (16).

Acknowledgements

Footnotes

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