Difficulties in assessing cytomegalovirus-associated gastric perforation in an HIV-infected patient
© Mégarbane et al; licensee BioMed Central Ltd. 2005
Received: 02 February 2005
Accepted: 13 April 2005
Published: 13 April 2005
Active Cytomegalovirus (CMV) infection is a common complication in advanced symptomatic Human Immunodeficiency Virus (HIV) infection. CMV-induced intestinal perforations are hard to diagnose and may be observed throughout the gastrointestinal tract. Isolated stomach perforation is exceptional.
A 47-year-old man was admitted to our intensive care unit with multiorgan failure. Gastrointestinal endoscopic examination showed erythematous gastritis but normal duodenum and colon. CMV blood culture was positive. Histologic examination of a gastric biopsy showed inflammatory infiltrate and immunostaining typical intranuclear CMV inclusion bodies. Concomitant abdominal CT scan disclosed large peripancreatic hypodensities without pneumoperitoneum. The patient died despite supportive therapies and ganciclovir infusion. Postmortem examination showed a 4-cm gastric perforation adhering to the transverse colon and liver, with a thick necrotic inflammatory coating around the pancreas. The whole GI tract, except the stomach, was normal. As other causes, especially Helicobacter pylori infection could be ruled out, a causal relationship between CMV and gastric disease was assumed.
CMV may be responsible for gastric perforations, with difficulties in assessing the diagnosis. Early diagnosis based on cautious endoscopy and histopathologic examination is needed to make a favorable outcome possible.
Cytomegalovirus (CMV) is frequently isolated from immunosuppressed patients with HIV infection, organ or bone marrow transplants, malignancies or immunosuppressive medications. CMV may cause disseminated diseases and is generally predictive, in HIV-infected patients, of poor long-term survival reflecting severe immunosuppression . In these patients, CMV gastrointestinal (GI) infection, including colitis, esophagitis, and gastritis [2, 3]. Clinical signs are usually sparse, making the diagnosis difficult. Although CMV-induced intestinal perforation has been observed in the patients with advanced immunodeficiency, isolated gastric perforation remains a rare event. We report here the fatal case of an HIV-infected patient, who presented a CMV-associated gastric perforation.
CMV infection of the GI tract can cause severe damage. Isolated involvement of the stomach is possible, although rare [3, 4]. Symptoms are not specific, including unexplained fever, dysphagia, sharp or postural epigastric pain, vomiting, diarrhea, and GI bleeding. Characteristic upper endoscopic findings are edema, congestion, mucosal ulcerations, multiple punched-out gastric ulcers, erosions, and upper GI hemorrhage . However, findings may be mild showing congestion and thickening or be atypical, with hemorrhaged necrotic gastritis or pseudo-tumors . Multiple mucosal biopsies are needed to detect CMV . In HIV-infected patients, CMV is significantly associated with chronic active gastritis or gastroduodenal ulcers [7–9], in contrast with healthy adults, in whom symptomatic CMV gastric infection is exceptional . Thus, early recognition of CMV GI infection, including blood cultures and cautious GI endoscopic evaluation, may allow for adequate therapy, preventing complications, such as life-threatening bleeding or perforation [3, 11].
CMV infection activates endothelial cells and leukocytes, altering GI microcirculation and inducing extensive vasculitis, thrombotic vascular occlusion, necrosis, and ischemic perforation . The most common reported locations of intestinal perforation are the colon (53%) [13–15], the distal ileum (40%) [16, 17], and the appendix (7%) . CMV-associated perforation of the stomach is a rare presentation . To our knowledge, isolated CMV-induced gastric perforation has only been reported in non-HIV organ transplant recipients . In our patient, CMV-associated gastric perforation, as a presenting manifestation of HIV infection, was responsible for multiorgan failure. The diagnosis was difficult, in the absence of acute abdomen and pneumoperitonium. Consistently, initial endoscopic examination missed the gastric perforation, since the hole in the stomach was probably filled in by peritoneum. Moreover it is possible that a suboptimal endoscopic evaluation of the upper GI tract was due to the patient's initial unstable condition and the performance of the gastroscopy in such a critical situation. In contrast, concomitant abdominal CT scan showed large hypodense images surrounding the pancreas, attributed after postmortem examination, to the hemorrhagic and necrotic inflammatory materials that filled in the gastric perforation.
Alternative causes of gastric ulcer, including Helicobacter pylori infection, should be discussed. Indeed, CMV is an opportunistic virus and may thus appear in previously damaged tissues. However, a recent study suggested that CMV, rather than Helicobacter pylori, may be the main causative pathogen of peptic ulcers in HIV-infected patients, in comparison to non HIV-infected ones . In our case, histopathologic findings and cultures were negative for Helicobacter pylori. Moreover, CMV inclusion bodies, which were observed on initial pathological findings, clearly indicated the existence of a CMV disease at the patient's admission.
Usually, resolution of symptoms and endoscopic findings is obtained with IV ganciclovir or foscarnet. Combined antiretroviral therapies may also be effective, even without specific treatment of CMV . However, in the case of perforation, despite immediate surgical resection and antiviral therapy, mortality rate remains elevated (> 80%), due to elevated operative mortality and increased postoperative complications [17, 18]. In our case, ganciclovir therapy successfully reduced CMV viral load before the occurrence of death, which resulted from misdiagnosed gastric perforation.
This dramatic presentation demonstrates that perforation may complicate CMV gastric infection in HIV-infected patients. Physicians should be aware that early diagnosis, based on cautious GI endoscopy and histopathologic examination of GI biopsy specimen is needed to make a favorable outcome possible.
Written consent was obtained from the patient relative for publication of study.
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