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Year : 2011  |  Volume : 54  |  Issue : 4  |  Page : 852-853
Cytomegalovirus esophagitis in nonimmunocompromised patient - Presenting as an acute necrotic (black) esophagitis


1 Department of Pathology, Kasturba Medical College, Manipal, India
2 Department of Gastroenterology, Kasturba Medical College, Manipal, India

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Date of Web Publication6-Jan-2012
 

How to cite this article:
Yagain K, Rao L, Pai K, Pai G. Cytomegalovirus esophagitis in nonimmunocompromised patient - Presenting as an acute necrotic (black) esophagitis. Indian J Pathol Microbiol 2011;54:852-3

How to cite this URL:
Yagain K, Rao L, Pai K, Pai G. Cytomegalovirus esophagitis in nonimmunocompromised patient - Presenting as an acute necrotic (black) esophagitis. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 May 24];54:852-3. Available from: http://www.ijpmonline.org/text.asp?2011/54/4/852/91526


Sir,

A 54 year old, alcoholic male presented to our hospital with recurrent episodes of hematemesis and melena since 2 days. On physical examination, he was found to have pallor and hepatomegaly. Laboratory investigations revealed elevated ALT (alanine amino-transferase 211 U/L) and elevated AST (aspartate amino-transferase 121 U/L) levels and elevated total and direct bilirubin (2.2 and 1 mg/dl, respectively). His serum total protein (5.4 g/dl) and albumin (3.3 g/dl) were mildly decreased, while serum globulin level was normal. All other parameters were within normal limits. Endoscopy showed denuded esophageal mucosa with hemorrhage and blackish discoloration. No varices were found. Aspergillosis was suspected. Multiple esophageal biopsies were taken and patient was asked to return for follow up after six weeks. Microscopic examination of the esophageal biopsy specimens showed ulcerated mucosa and overlying granulation tissue [Figure 1]. Necrotic slough with candidal pseudohyphae were seen on the surface. Intranuclear Cytomegalovirus (CMV) inclusions were found in the endothelial cells, few incipient intracytoplasmic inclusions were also found [Figure 2]. A diagnosis of CMV esophagitis and candidiasis was made. However, a follow up esophagoscopy after 5 weeks showed normal appearing mucosa with fine nodular appearance in the mid esophagus with no evidence of denudation or ulceration of the mucosa. Repeat biopsy showed normal histology with no evidence of CMV inclusions or candida. Tests for Human Immunodeficiency Virus (HIV) 1 and 2 infections were performed after the histopathology report and were negative. Total Immunoglobulin G (IgG) levels' test and serology for CMV were not done as the patient could not afford the tests and the lesions' resolved without any treatment.
Figure 1: Histopathologic examination of the esophageal biopsy specimens of the patient showing ulcerated mucosa and overlying granulation tissue (Hematoxylin and Eosin, ×50)

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Figure 2: CMV inclusions (arrow). (Hematoxylin and Eosin, ×400). Inset shows intranuclear inclusions surrounded by halo (Hematoxylin and Eosin, ×oil immersion 1000]

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CMV infection with gastro-intestinal involvement is well documented in immunocompromised hosts such as individuals with acquired immunodeficiency syndrome (AIDS), solid organ transplant recipients, allogeneic bone marrow patients, individuals with hematological malignancies and patients undergoing chemotherapy or high dose steroid therapy. [1] CMV infection has been reported in malnourished patients, critical care patients in intensive care units and patients with extensive burns or severe trauma who are considered non-immunocompromised patients. [1] Alcohol causes immunomodulation but not immunosuppression. [1] Further, alcoholics have increased tendency to have bacterial infections rather than viral infections. [2] Literature review revealed only few cases of CMV esophagitis in non-immunocompromised hosts. [1],[3] In these subjects, active infection is rare; when it occurs, it is due to endogenous reactivation from exogenous reinfection with another virus strain. [1] The most common site of GI (gastrointestinal) involvement is the colon, followed by upper GI tract; and the least common site is the small intestine. [1] The esophageal mucosa appears to be rarely infected by CMV in non-immunocompromised patients, although it represents the most common site of GI involvement in immunocompromised patients. [1]

The most common symptoms of CMV esophagitis are dysphagia and odynophagia. Hemorrhage, although a common presenting manifestation in CMV, involvement of rest of the GI tract is extremely rare in esophagitis. [3] One case of CMV esophagitis presenting with massive esophageal bleeding has been reported. [3] Acute esophageal necrosis (black esophagus) was reported in a renal transplant recipient as a manifestation of primary cytomegalovirus infection. [4] The present case was a non-immunocompromised individual with no prior esophageal disease or concomitant major catabolic illness. Reactivation of past latent CMV infection could have been triggered by malnutrition associated with chronic alcoholism as suggested by decreased serum albumin and total protein levels. However, once the patient recovered from malnutrition, he probably, recuperated from CMV infection without specific antiviral treatment. As previously reported, symptomatic CMV infections in nonimmunocompromised individuals usually require supportive care only, and our case was not an exception. [5]

In conclusion, diagnosing CMV infection in the GI tract calls for a high index of suspicion; especially, while dealing with small biopsy specimens from non-immunocompromised hosts. Possibility must be considered mainly in those cases where endoscopic examination has shown evidence of erosions and/or ulcers. Early diagnosis is crucial to enable prompt and effective antiviral treatment.

 
   References Top

1.Maiorana A, Baccarini P, Foroni M, Bellini N, Giusti F.Human cytomegalovirus Infection of the gastrointestinal tract in apparently immunocompetent patients. Hum Pathol 2003;34:1331-6  Back to cited text no. 1
    
2.Szabo G. Consequences of alcohol consumption on host defence. Alcohol Alcohol 1999;34:830-41.  Back to cited text no. 2
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3.Featherstone RJ, LG Camero, R Khatib, Daniel S, Praveena M. Massive esophageal bleeding in Achalasia complicated by cytomegalovirus esophagitis. Ann Thorac Surg 1995;59:1021-2.  Back to cited text no. 3
    
4.Trappe R, Pohl H, Forberger A, Schindler R, Reinke P. Acute esophageal necrosis (black esophagus) in the renal transplant recipient: Manifestation of primary cytomegalovirus infection. Transpl Infect Dis 2007;9:42-5  Back to cited text no. 4
    
5.Goff JS. Infectious causes of esophagitis. Ann Rev Med 1988;39:163-9.  Back to cited text no. 5
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Correspondence Address:
Kiran Yagain
Department of Pathology, Kasturba Medical College, Manipal - 576 104
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.91526

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