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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. pj.ca.uykuyr-u.dem@a-amakoh
Telephone: +81-98-8951144 Fax: +81-98-8951414
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.
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 (Figure1A).1A). The erythema was slightly depressed (Figure (Figure1B).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 (Figure1C)1C) compatible with cytomegalovirus (CMV) infection. Positive immunostaining for CMV antigens confirmed the diagnosis of CMV gastritis (Figure (Figure1D).1D). The gastritis improved with the treatment of ganciclovir.
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. 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, 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. 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.
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
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