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Wang Y, Lin X, Li Y, Wen Y. Multiple small bowel perforations due to cytomegalovirus related immune reconstitution inflammatory syndrome in an HIV patient: A case report. Medicine (Baltimore) 2021; 100:e26605. [PMID: 34260544 PMCID: PMC8284711 DOI: 10.1097/md.0000000000026605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/22/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE The presentation of multiple intestinal perforations is a severe complication of enteric cytomegalovirus (CMV) infection, sometimes associated with immune reconstitution inflammatory syndrome (IRIS) after the initiation of antiretroviral therapy (ART) in patients with human immunodeficiency virus (HIV). Here we reported a rare case of a patient with HIV infection who developed multiple perforations in the small bowel shortly after ART initiation without any prodromal gastrointestinal symptoms. We also reviewed the literature of reported cases to clarify their clinical characteristics for early diagnosis and rapid intervention. PATIENT CONCERNS A patient with HIV presented with fever after 16 days of ART initiation and was admitted to our hospital. He was treated with intravenous ganciclovir due to persistent CMV viremia. The fever resolved 10 days later. However, he reported persistent left lower abdominal pain. DIAGNOSES The patient was diagnosed with multiple small bowel perforations, CMV-related IRIS, and acquired immune deficiency syndrome. An upright abdominal x-ray in a tertiary level hospital revealed bilateral moderate intraperitoneal free air. We performed a pathological examination and metagenomic next-generation sequencing. CMV enteritis was confirmed by immunohistochemical staining and other opportunistic infections were excluded by metagenomic next-generation sequencing. INTERVENTIONS The patient was treated with intravenous ganciclovir and 24 hours later, the patient underwent exploratory laparotomy. Partial resection and surgical repair of the small intestine were performed. OUTCOMES The patient ultimately died from intestinal obstruction and septic shock 55 days after surgery. LESSONS Perforations due to CMV-related IRIS are very rare, and usually appear shortly after ART initiation. Most cases lack the prodromal symptoms of abdominal pain and diarrhea. Intestinal perforations are lethal, and early detection and surgical treatment are lifesaving.
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Affiliation(s)
- Yanli Wang
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xuyong Lin
- Pathology Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yuji Li
- Gastrointestinal Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ying Wen
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
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Lee YC, Chiou CC, Wang JT, Yang YC, Tung SH, Hsieh SM. Non-traumatic perforation of the jejunum in a human immunodeficiency virus-infected patient receiving combination antiretroviral therapy: A case report. Medicine (Baltimore) 2019; 98:e18163. [PMID: 31804330 PMCID: PMC6919416 DOI: 10.1097/md.0000000000018163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Non-traumatic bowel perforation caused by cytomegalovirus (CMV) and Mycobacterium avium complex (MAC) infections has become rare among patients with acquired immunodeficiency syndrome (AIDS) in the era of combination antiretroviral therapy (cART); however, CMV-associated and MAC-related immune reconstitution inflammatory syndrome (IRIS) has subsequently emerged owing to the wide use of integrase inhibitor-based regimens. Here we report a case of spontaneous perforation of the jejunum in a patient with human immunodeficiency virus (HIV) infection with good compliance to cART. PATIENT CONCERNS A 32-year-old HIV-infected man developed CMV disease and DMAC infection, as unmasking IRIS, 3 days after the initiation of cART. After appropriate treatment for opportunistic infections, intermittent fever with enlarged lymph nodes in the abdomen occurred as paradoxical IRIS. The patient was administered prednisolone with subsequent tapering according to his clinical condition. DIAGNOSES Unexpected perforation of hollow organ during the titration of steroid dose with clinical presentations of severe abdominal pain was diagnosed by chest radiography. INTERVENTIONS He underwent surgical repair with peritoneal toileting smoothly. OUTCOMES He was discharged well with a clean surgical wound on post-operative day 10. LESSONS Bowel perforation may be a life-threatening manifestation of IRIS in the era of cART. Steroids should be avoided, if possible, to decrease the risk of bowel perforation, especially in IRIS occurred after opportunistic diseases involving the gastrointestinal tract.
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Affiliation(s)
- Yi-Chien Lee
- Department of Internal Medicine, Fu Jen Catholic University Hospital
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City
| | - Chien-Chun Chiou
- Department of Dermatology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Institute for Infectious Diseases and Vaccinology, National Health Research Institutes
| | - Yi-Chun Yang
- Department of Nursing, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Shao-Hsien Tung
- Department of Internal Medicine, Fu Jen Catholic University Hospital
| | - Szu-Min Hsieh
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
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Cytomegalovirus and the Seemingly Immunocompetent Host: A Case of a Perforating Gastric Ulcer. ACG Case Rep J 2017; 4:e27. [PMID: 28286792 PMCID: PMC5340719 DOI: 10.14309/crj.2017.27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/14/2016] [Indexed: 12/12/2022] Open
Abstract
Cytomegalovirus (CMV) infection of the gastrointestinal tract has a variety of presentations. We present a case of gastric perforation, which is a relatively infrequent presentation of CMV infection. If the cause of gastric perforation is not readily apparent, testing for CMV should be considered. If CMV workup is positive, an evaluation for immunocompromise is prudent as CMV infections are more common in immunocompromised individuals.
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Boteon YL, Alves IPF, da Silva APC, Junior VT, de Souza Coelho Neto J, Lopes LR, de Carvalho Ramos M, Andreollo NA. Obstructive Gastric Pseudotumor Caused by Cytomegalovirus in an AIDS Patient: A Case Report and Review of Surgical Treatment. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:536-541. [PMID: 26277259 PMCID: PMC4542526 DOI: 10.12659/ajcr.894070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 05/11/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a common opportunistic pathogen in patients with HIV. It is also a major cause of gastrointestinal ulcers in patients with acquired immunodeficiency syndrome (AIDS). CMV pseudotumor in the stomach is a rare cause of digestive tract obstruction. CASE REPORT In this study we report a male patient infected with HIV in 2002. In 2014 he evolved C3 stage AIDS with pre-pyloric gastric ulcer which provoked deformity and pseudotumoral aspect of the gastric outlet. Endoscopic biopsy confirmed CMV infection. He underwent Roux-en-Y gastroenteroanastomosis with good recovery. CONCLUSIONS CMV infection should be considered as an agent in gastric lesions in HIV-infected patients. Roux-en-Y gastroenteroanastomosis is a surgical option for this group of patients, allowing improvements in quality of life and decreasing risks of perioperative complications.
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Affiliation(s)
- Yuri Longatto Boteon
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp) and in the Diagnostic Center for Digestive Diseases (Gastrocentro), Unicamp, Campinas, Sao Paulo, Brazil
| | - Iuri Pedreira Filardi Alves
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp) and in the Diagnostic Center for Digestive Diseases (Gastrocentro), Unicamp, Campinas, Sao Paulo, Brazil
| | - Amanda Pinter Carvalheiro da Silva
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp) and in the Diagnostic Center for Digestive Diseases (Gastrocentro), Unicamp, Campinas, Sao Paulo, Brazil
| | - Valdir Tercioti Junior
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp) and in the Diagnostic Center for Digestive Diseases (Gastrocentro), Unicamp, Campinas, Sao Paulo, Brazil
| | - João de Souza Coelho Neto
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp) and in the Diagnostic Center for Digestive Diseases (Gastrocentro), Unicamp, Campinas, Sao Paulo, Brazil
| | - Luiz Roberto Lopes
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp) and in the Diagnostic Center for Digestive Diseases (Gastrocentro), Unicamp, Campinas, Sao Paulo, Brazil
| | - Marcelo de Carvalho Ramos
- Department of Clinical Medicine, Faculty of Medical Sciences, State University of Campinas (Unicamp) and in the Diagnostic Center for Digestive Diseases (Gastrocentro), Unicamp, Campinas, Sao Paulo, Brazil
| | - Nelson Adami Andreollo
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas (Unicamp) and in the Diagnostic Center for Digestive Diseases (Gastrocentro), Unicamp, Campinas, Sao Paulo, Brazil
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Koc B, Bircan HY, Altaner S, Cinar O, Ozcelik U, Yavuz A, Kemik O. Massive Alimentary Tract Bleeding due to Cytomegalovirus Infection in an Elderly Patient. Infect Dis Rep 2014; 6:5512. [PMID: 25276331 PMCID: PMC4178269 DOI: 10.4081/idr.2014.5512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 08/19/2014] [Accepted: 08/19/2014] [Indexed: 01/17/2023] Open
Abstract
In recent years, cytomegalovirus (CMV) has been recognized as an important common pathogen in immunocompromized patients. This is due to the increasing number of immunosuppressive medications, intensive cancer chemotherapy use, recurrent transplantations, progressively aging population, and the higher number of human immunodeficiency virus infections. Cytomegalovirus infection especially interests the gastrointestinal tract, anywhere, from the mouth to the anus. Namely, the most commonly affected area is the colon, followed by duodenum, stomach, esophagus and small intestine. The most frequent manifestations of CMV colitis are: diarrhea, fever, gastrointestinal bleeding and abdominal pain. We report here the case of an 82-year-old woman, who was treated for non-Hodgkin lymphoma; she was admitted to the emergency department for abdominal pain and diffuse arthralgia, following massive upper- and lower- gastrointestinal bleeding, due to duodenal and colonic ulcers related to CMV infection.
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Affiliation(s)
- Bora Koc
- Department of Surgery, Baskent University, Istanbul Research Hospital, Van, Turkey
| | - Huseyin Yuce Bircan
- Department of Surgery, Baskent University, Istanbul Research Hospital, Van, Turkey
| | - Semsi Altaner
- Department of Pathology, Baskent University, Istanbul Research Hospital, Van, Turkey
| | - Ozlem Cinar
- Department of Anesthesia, Intensive Care Unit, Faculty of Medicine, Baskent University, Istanbul Research Hospital, Van, Turkey
| | - Umit Ozcelik
- Department of Surgery, Baskent University, Istanbul Research Hospital, Van, Turkey
| | - Alpaslan Yavuz
- Department of Radiology, Yuzuncu Yil University, Van, Turkey
| | - Ozgur Kemik
- Department of General Surgery, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
- Yuzuncu Yil University Medical Faculty, Department of Surgery, Kampus, Ercis Yolu, Van, Turkey. +90.505.5566969 - +90.432.4251024.
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Jun YJ, Sim J, Ahn HI, Han H, Kim H, Yi K, Rehman A, Jang SM, Jang K, Paik SS. Cytomegalovirus enteritis with jejunal perforation in a patient with endometrial adenocarcinoma. World J Clin Cases 2013; 1:220-223. [PMID: 24340271 PMCID: PMC3856296 DOI: 10.12998/wjcc.v1.i7.220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 02/05/2023] Open
Abstract
Cytomegalovirus (CMV) infection of the gastrointestinal tract has been reported most frequently in the setting of immunodeficiency. The whole gastrointestinal tract can be affected; however, the small bowel is rarely affected. We report a case of CMV enteritis with jejunal perforation in a 53-year-old woman with a history of chemoradiation therapy for endometrial cancer 8 years previously. At follow-up evaluation, lower abdominal pain, diarrhea and vomiting appeared. Abdominal computed tomography showed intra-abdominal free air in the subphrenic space and porta hepatis. The jejunal segment revealed serosal purulent exudates with a perforation. The resected jejunal segment showed a large geographic ulcerative mucosal lesion. The microscopic findings revealed a diffuse ulcerative mucosal change with a prominent granulation tissue formation and many large atypical vascular endothelial cells and stromal fibroblasts with intranuclear or intracytoplasmic inclusion bodies. These cells were positive for CMV antibody. The final diagnosis was CMV-associated jejunitis with a jejunal perforation.
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Fujikawa H, Araki T, Shimura T, Okita Y, Tanaka K, Inoue M, Kawamura M, Inoue Y, Mohri Y, Uchida K, Kusunoki M. Small intestinal perforation caused by cytomegalovirus reactivation after subtotal colectomy for ulcerative colitis: report of a case. Clin J Gastroenterol 2013; 6:111-5. [PMID: 26181447 DOI: 10.1007/s12328-013-0360-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 01/15/2013] [Indexed: 10/27/2022]
Abstract
A 79-year-old woman with bloody diarrhea was diagnosed with ulcerative colitis. She developed intestinal perforation after high-dose steroid therapy. An emergency laparotomy revealed a perforation in the ascending colon, and a subtotal colectomy was performed with an ileostomy and a mucous fistula in the sigmoid colon. Histological findings of the resected colon showed the presence of cytomegalovirus in the endothelial cells of vessels around the ulcer floor. Twelve days after the laparotomy, she developed an ileal perforation with a bloody discharge from the ileostomy and underwent an emergency laparotomy. Multiple intestinal perforations were found in the ileum, and the perforated ileum was resected. Cytomegalovirus infection was controlled with ganciclovir postoperatively. Histological findings of the resected ileum showed the presence of cytomegalovirus in the endothelial cells of vessels around the ulcer floor. This is the first report of ileal perforation due to cytomegalovirus infection confirmed pathologically in a patient with ulcerative colitis.
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Affiliation(s)
- Hiroyuki Fujikawa
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Toshimitsu Araki
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tadanobu Shimura
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yoshiki Okita
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Koji Tanaka
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Mikihiro Inoue
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Mikio Kawamura
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Inoue
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiko Mohri
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Keiichi Uchida
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masato Kusunoki
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie, 514-8507, Japan
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Michalopoulos N, Triantafillopoulou K, Beretouli E, Laskou S, Papavramidis TS, Pliakos I, Hytiroglou P, Papavramidis ST. Small bowel perforation due to CMV enteritis infection in an HIV-positive patient. BMC Res Notes 2013; 6:45. [PMID: 23379792 PMCID: PMC3568738 DOI: 10.1186/1756-0500-6-45] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Accepted: 01/28/2013] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cytomegalovirus infection of the gastrointestinal tract is common and is more often seen in patients with acquired immunodeficiency syndrome (AIDS). Although small bowel infection is less common than infection of other parts of the gastrointestinal system, it may lead to perforation, an acute complication, with dreadful results. CASE PRESENTATION This article reports a case of Cytomegalovirus ileitis with multiple small bowel perforations in a young man with human immunodeficiency virus (HIV) infection. The patient developed abdominal pain with diarrhea and fever, and eventually acute abdomen with pneumoperitoneum. The patient had poor prognosis and deceased despite the prompt surgical intervention and the antiviral therapy he received. At pathology a remarkable finding was the presence of viral inclusions in smooth muscle fibers. The destruction of muscle cells was the main cause of perforation. CONCLUSION Morbidity and mortality associated with perforation from CMV enteritis in AIDS patients are high and the life expectancy is short. Cytomegalovirus disease is multifocal; therefore, excision of one portion of the gastrointestinal tract may be followed by a complication elsewhere. Our case elucidate that muscle cell destruction by the virus is a significant cause leading to perforation.
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Affiliation(s)
- Nick Michalopoulos
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Abstract
The most common complaints among patients with cancer who present to the emergency department are related to the gastrointestinal system, and 40% of these patients complain of abdominal pain. These presentations can stem from the underlying malignancy itself, treatment directed toward the disease, or the full range of pathologies present in a healthy population. Immunosuppression may blunt many of the findings one expects in a healthy population of patients, thus rendering the clinical exam less reliable in many patients with cancer. Moreover, the degree of immunosuppression shapes both the types of pathologies the clinician should consider and the rate at which the disease may progress. Understanding the limitations of physical examination, pathophysiology of disease, and the methods by which these diagnoses are established is of critical importance in this population. This article focuses specifically on patients with cancer who present with an acute abdomen, and it discusses how a concurrent malignancy can shape the differential diagnosis in these cases.
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Affiliation(s)
- Jonathan S Ilgen
- Department of Emergency Medicine, Oregon Health & Science University, CDW-EM, Portland, OR 97239, USA.
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