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Gastroenterologie
a hepatologie

Gastroenterology and Hepatology

Gastroent Hepatol 2021; 75(4): 304–310. doi:10.48095/ccgh2021304.

CMV enteritis as unusual source of bleeding to GIT

David Varyš1, Janka Slatinská2, Veronika Pítová1, Klára Chmelová1, Julius Špičák Orcid.org  1, Jiří Novotný3, Jiří Fabián4, Jan Šperl Orcid.org  1, Soňa Fraňková Orcid.org  1

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Summary

Introduction: Cytomegalovirus disease affecting the gastrointestinal tract is a rare but severe disease presenting particularly in people under immunosuppression, solid organ transplant recipients and AIDS patients with CD4 count under 100/mm3. When colon or small intestine are affected, the disease may be complicated by severe bleeding. CMV therapy includes antivirals and, in case of bleeding, methods of therapeutic endoscopy or interventional radiology. Case description: We present a case of a 74-year-old woman 3 years after kidney transplantation owing to vascular nephrosclerosis, treated with belatacept, mycophenolate mophetile and prednisone. She was admitted to hospital for acute dyspnoea. During hospitalisation, she presented with intestinal bleeding, but the endoscopic intervention at the first colonoscopy was not successful. She was referred to the Department of Hepatogastroenterology of the Institute of Clinical and Experimental Medicine and subsequent colonoscopy revealed a 15 cm long part of ileum with ulcerations as the source of bleeding. The histological assessment described a severe CMV enteritis. The CMV DNA blood level established by PCR was higher than 10 000 000 U/ml. The patient was treated with intravenous ganciclovir and she underwent selective embolization of the inferior mesenteric artery with an excellent clinical effect. Conclusions: CMV enteritis may be associated with a high mortality. The approach to therapy is multidisciplinary and needs collaboration of gastroenterologist, endoscopist and interventional radiologist.

Key words: CMV – GIT bleeding – immunosuppression – transplantation


Keywords

GIT bleeding, immunosuppression

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Literature

Literatura

1. Stadler LP, Bernstein DI, Callahan ST et al. Seroprevalence of cytomegalovirus (CMV) and risk factors for infection in adolescent males. Clin Infect Dis 2010; 51 (10): e76–81. doi: 10.1086/656918.

2. Cannon MJ, Schmid DS, Hyde TB. Review of cytomegalovirus seroprevalence and demographic characteristics associated with infection. Rev Med Virol 2010; 20 (4): 202–213. doi: 10.1002/rmv.655.

3. Evans AS. Infectious mononucleosis and related syndromes. Am J Med Sci 1978; 276 (3): 325–339. doi: 10.1097/00000441-197811000-00 010.

4. Sinclair J. Human cytomegalovirus: latency and reactivation in the myeloid lineage. J Clin Virol 2008; 41 (3): 180–185. doi: 10.1016/j.jcv.2007.11.014.

5. Stanier P, Taylor DL, Kitchen AD et al. Persistence of cytomegalovirus in mononuclear cells in peripheral blood from blood donors. BMJ 1989; 299 (6704): 897–898. doi: 10.1136/bmj.299.6704.897.

6. Leonardsson H, Hreinsson JP, Love A et al. Hepatitis due to Epstein-Barr virus and cytomegalovirus: clinical features and outcomes. Scand J Gastroenterol 2017; 52 (8): 893–897. doi: 10.1080/00365521.2017.1319972.

7. Bonnet F, Neau D, Viallard JF et al. Clinical and laboratory findings of cytomegalovirus infection in 115 hospitalized non-immunocompromised adults. Ann Med Interne (Paris) 2001; 152 (4): 227–235.

8. Kalil AC, Florescu DF. Prevalence and mortality associated with cytomegalovirus infection in nonimmunosuppressed patients in the intensive care unit. Crit Care Med 2009; 37 (8): 2350–2358. doi: 10.1097/CCM.0b013e3181a3aa43.

9. Chmelova K, Frankova S, Jirsa M et al. IL28B rs12979860 T allele protects against CMV disease in liver transplant recipients in the post-prophylaxis and late period. Transpl Infect Dis 2019; 21 (4): e13124. doi: 10.1111/tid.13124.

10. Hibberd PL, Tolkoff-Rubin NE, Cosimi AB et al. Symptomatic cytomegalovirus disease in the cytomegalovirus antibody seropositive renal transplant recipient treated with OKT3. Transplantation 1992; 53 (1): 68–72. doi: 10.1097/00007890-199201000-00013.

11. Drouet E, Colimon R, Michelson S et al. Monitoring levels of human cytomegalovirus DNA in blood after liver transplantation. J Clin Microbio­l 1995; 33 (2): 389–394. doi: 10.1128/jcm.33.2.389-394.1995.

12. Murray BM. Management of cytomegalovirus infection in solid-organ transplant recipients. Immunol Invest 1997; 26 (1–2): 243–255. doi: 10.3109/08820139709048930.

13. Chou S. Newer methods for dia­gnosis of cytomegalovirus infection. Rev Infect Dis 1990; 12 Suppl 7: S727–S736. doi: 10.1093/clinids/12.supplement_7.s727.

14. Kraft CS, Armstrong WS, Caliendo AM. Interpreting quantitative cytomegalovirus DNA testing: understanding the laboratory perspective. Clin Infect Dis 2012; 54 (12): 1793–1797. doi: 10.1093/cid/cis212.

15. Kotton CN, Kumar D, Caliendo AM et al. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation 2013; 96 (4): 333–360. doi: 10.1097/TP.0b013e31829df29d.

16. Talley NJ, Jones M. Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking. Am J Gastroenterol 1998; 93 (11): 2179–2183. doi: 10.1111/j.1572-0241.1998.00530.x.

17. Dent OF, Goulston KJ, Zubrzycki J et al. Bowel symptoms in an apparently well population. Dis Colon Rectum 1986; 29 (4): 243–247. doi: 10.1007/BF02553027.

18. Korkis AM, McDougall CJ. Rectal bleeding in patients less than 50 years of age. Dig Dis Sci 1995; 40 (7): 1520–1523. doi: 10.1007/BF02285201.

19. Helfand M, Marton KI, Zimmer-Gembeck MJ et al. History of visible rectal bleeding in a primary care population. Initial assessment and 10-year follow-up. JAMA 1997; 277 (1): 44–48.

20. Chavalitdhamrong D, Jensen DM, Kovacs TO et al. Ischemic colitis as a cause of severe hematochezia: risk factors and outcomes compared with other colon dia­gnoses. Gastrointest Endosc 2011; 74 (4): 852–857. doi: 10.1016/j.gie.2011.05.039.

21. Kaufmann HJ, Taubin HL. Nonsteroidal anti-inflammatory drugs activate quiescent inflammatory bowel disease. Ann Intern Med 1987; 107 (4): 513–516. doi: 10.7326/00 03-4819-107-4-513.

22. Jensen DM, Machicado GA. Dia­gnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988; 95 (6): 1569–1574. doi: 10.1016/s0016-5085 (88) 80079-9.

23. Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol 2010; 105 (12): 2636–2641. doi: 10.1038/ajg.2010.277.

24. Sissons JG, Carmichael AJ. Clinical aspects and management of cytomegalovirus infection. J Infect 2002; 44 (2): 78–83. doi: 10.1053/jinf.2001.0949.

25. Galiatsatos P, Shrier I, Lamoureux E et al. Meta-analysis of outcome of cytomegalovirus colitis in immunocompetent hosts. Dig Dis Sci 2005; 50 (4): 609–616. doi: 10.1007/s106 20-005-2544-6.

26. Levin A, Yaari S, Stoff R et al. Dia­gnosis of cytomegalovirus infection during exacerbation of ulcerative colitis. Digestion 2017; 96 (3): 142–148. doi: 10.1159/000479865.

27. Morunglav M, Theate I, Bertin G et al. CMV enteritis causing massive intestinal hemorrhage in an elderly patient. Case Rep Med 2010; 2010. doi: 10.1155/2010/385795.

28. Keates J, Lagahee S, Crilley P et al. CMV enteritis causing segmental ischemia and massive intestinal hemorrhage. Gastrointest Endosc 2001; 53 (3): 355–359. doi: 10.1016/s0016-510 7 (01) 70417-8.

29. Dolgin SE, Larsen JG, Shah KD et al. CMV enteritis causing hemorrhage and obstruction in an infant with AIDS. J Pediatr Surg 1990; 25 (6): 696–698. doi: 10.1016/0022-3468 (90) 90369-k.

30. Randomised trial comparing tacrolimus (FK506) and cyclosporin in prevention of liver allograft rejection. European FK506 Multicentre Liver Study Group. Lancet 1994; 344 (8920): 423–428.

31. Mayer AD, Dmitrewski J, Squifflet JP et al. Multicenter randomized trial comparing tacrolimus (FK506) and cyclosporine in the prevention of renal allograft rejection: a report of the European Tacrolimus Multicenter Renal Study Group. Transplantation 1997; 64 (3): 436–443. doi: 10.1097/00007890-199708150-00012.

32. Karadkhele G, Hogan J, Magua W et al. CMV high-risk status and posttransplant outcomes in kidney transplant recipients treated with belatacept. Am J Transplant 2021; 21 (1): 208–221. doi: 10.1111/ajt.16132.

33. Chavarot N, Divard G, Scemla A et al. Increased incidence and unusual presentations of CMV disease in kidney transplant recipients after conversion to belatacept. Am J Transplant 2021; 21 (7): 2448–2458. doi: 10.1111/ajt.16430.

34. van Rongen I, Thomassen BJW, Perk LE. Early versus standard colonoscopy: a randomized controlled trial in patients with acute lower gastrointestinal bleeding: results of the BLEED study. J Clin Gastroenterol 2019; 53 (8): 591–598. doi: 10.1097/MCG.0000000000001 048.

35. Green BT, Rockey DC, Portwood G et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol 2005; 100 (11): 2395–2402. doi: 10.1111/j.1572-0241.2005.00306.x.

36. Kuhle WG, Sheiman RG. Detection of active colonic hemorrhage with use of helical CT: findings in a swine model. Radiology 2003; 228 (3): 743–752. doi: 10.1148/radiol.2283020 756.

37. Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol 2010; 8 (4): 333–343. doi: 10.1016/j.cgh.2009.12.017.


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