Letters To The Editor
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World J Gastrointest Endosc. Nov 16, 2010; 2(11): 379-380
Published online Nov 16, 2010. doi: 10.4253/wjge.v2.i11.379
Cytomegalovirus gastritis
Akira Hokama, Kiyohito Taira, Yu-ichi Yamamoto, Nagisa Kinjo, Fukunori Kinjo, Kenzo Takahashi, Jiro Fujita
Akira Hokama, Jiro Fujita, Department of Infectious, Respiratory, and Digestive Medicine, Faculty of Medicine, University of the Ryukyus, Okinawa 903-0125, Japan
Kiyohito Taira, Yu-ichi Yamamoto, Kenzo Takahashi, Department of Dermatology, Faculty of Medicine, University of the Ryukyus, Okinawa 903-0125, Japan
Nagisa Kinjo, Fukunori Kinjo, Department of Endoscopy, University Hospital of the Ryukyus, Okinawa 903-0125, Japan
Author contributions: Hokama A wrote the manuscript; Taira K and Yamamoto Y treated the patient; Kinjo N performed the endoscopic examination; and Kinjo F, Takahashi K and Fujita J supervised the treatment of the patient and preparation of the manuscript.
Correspondence to: Akira Hokama, MD, PhD, Assistant Professor, Department of Infectious, Respiratory, and Digestive Medicine, Faculty of Medicine, University of the Ryukyus, Okinawa 903-0125, Japan. hokama-a@med.u-ryukyu.ac.jp
Telephone: +81-98-8951144 Fax: +81-98-8951414
Received: June 7, 2010
Revised: August 21, 2010
Accepted: August 28, 2010
Published online: November 16, 2010

Abstract

Cytomegalovirus (CMV) has been increasingly recognized as an important common pathogen in an immunocompromised state. The colon and stomach are the most common sites of its gastrointestinal infection. Symptoms of CMV gastritis are usually nonspecific and include epigastric pain, fever, nausea and bleeding. Endoscopic features are quite variable and include macroscopically normal mucosa, diffuse erythema, nodules, pseudotumors, erosions and ulcers. The bioptic detection of intranuclear inclusions is the hallmark of CMV infection. Most gastrointestinal CMV infection responds well to ganciclovir. We present endoscopic and histopathological features of CMV gastritis in a 71 year old woman receiving long-term prednisolone for pemphigus vulgaris.

Key Words: Cytomegalovirus, Gastritis, Pemphigus vulgaris, Endoscopy


Citation: Hokama A, Taira K, Yamamoto YI, Kinjo N, Kinjo F, Takahashi K, Fujita J. Cytomegalovirus gastritis. World J Gastrointest Endosc 2010; 2(11): 379-380
TO THE EDITOR

A 71 year old woman who had been receiving long-term prednisolone for pemphigus vulgaris underwent upper gastrointestinal endoscopy for screening. She denied having abdominal symptoms. On examination, there was no tenderness on abdominal palpation and normal bowel sounds. Endoscopic examination revealed numerous patchy erythemas in the gastric body (Figure 1A). The erythema was slightly depressed (Figure 1B). The histopathological examination of the lesion showed large epithelial cells with characteristic “owl’s eye” eosinophilic intranuclear inclusion body surrounded by a clear halo (Figure 1C) compatible with cytomegalovirus (CMV) infection. Positive immunostaining for CMV antigens confirmed the diagnosis of CMV gastritis (Figure 1D). The gastritis improved with the treatment of ganciclovir.

Figure 1
Figure 1 Endoscopic and histopathological pictures of cytomegalovirus gastritis. A: Note numerous patchy erythemas in the gastric body; B: Closer observation showing the slightly depressed erythema; C: Histopathological examination of the erythema showing large epithelial cells with characteristic “owl’s eye” eosinophilic intranuclear inclusion body surrounded by a clear halo (H&E, × 200); D: Note positive immunostaining for cytomegalovirus antigens × 200).

CMV has been increasingly recognized as an important common pathogen in an immunocompromised state including those caused by immunosuppressive medications, cancer chemotherapy, transplant recipients, aging and human immunodeficiency virus infection[1]. The colon and stomach are the most common sites of its gastrointestinal infection. Although postural epigastric pain has been described as a sign of CMV gastritis[2], symptoms of this disorder are usually nonspecific and include epigastric pain, fever, nausea and bleeding. Endoscopic features are quite variable and include macroscopically normal mucosa, diffuse erythema, nodules, pseudotumors, erosions and ulcers. Although the bioptic detection of “owl’s eye” is the hallmark of CMV infection, classical intranuclear inclusions are not always found because CMV may infect vascular endothelium or connective tissue stromal cells under the ulcers as well as mucosal epithelium[3]. Therefore, several diagnostic tools have been coupled for the suspected infection including CMV antigenemia assay and polymerase chain reaction of the specimen[4,5]. Most gastrointestinal CMV infection responds well to ganciclovir regardless of the cause of the underlying immunosuppression.

Footnotes

Peer reviewers: Antonio Tucci, Gastrointestinal Unit, Castel S. Pietro Terme Hospital, University of Bologna, Bologna 41036, Italy; Shuji Yamamoto, MD, Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan; Jayesh Sagar, MBBS, MS, MRCS, MD, Surgical Registrar, Royal Sussex County Hospital, Brighton, BN2 5BE, United Kingdom; Seamus Joseph Murphy, MB, BCh, MRCP, PhD, Consultant Gastroenterologist, Department of Medicine, Daisy Hill Hospital, 5 Hospital Road, Newry, Co. Down, BT35 9YE, Northern Ireland, United Kingdom

S- Editor Zhang HN L- Editor Roemmele A E- Editor Liu N

References
1.  Goodgame RW. Gastrointestinal cytomegalovirus disease. Ann Intern Med. 1993;119:924-935.  [PubMed]  [DOI]
2.  Li W, Fan H, Yiping L. Postural epigastric pain as a sign of cytomegalovirus gastritis in renal transplant recipients: a case-based review. Transplant Proc. 2009;41:3956-3958.  [PubMed]  [DOI]
3.  Chetty R, Roskell DE. Cytomegalovirus infection in the gastrointestinal tract. J Clin Pathol. 1994;47:968-972.  [PubMed]  [DOI]
4.  Gandhi MK, Khanna R. Human cytomegalovirus: clinical aspects, immune regulation, and emerging treatments. Lancet Infect Dis. 2004;4:725-538.  [PubMed]  [DOI]
5.  Jang EY, Park SY, Lee EJ, Song EH, Chong YP, Lee SO, Choi SH, Woo JH, Kim YS, Kim SH. Diagnostic performance of the cytomegalovirus (CMV) antigenemia assay in patients with CMV gastrointestinal disease. Clin Infect Dis. 2009;48:e121-e124.  [PubMed]  [DOI]