J Rheum Dis.  2013 Jun;20(3):172-176. 10.4078/jrd.2013.20.3.172.

Multiple Gastric Ulcers as a Manifestation of Cytomegalovirus Infection in a Patient with Adult-onset Still's Disease

• Kwon MH
• Lee CS
• Cho SW
• Joung CI

• KMID: 2222756
• DOI: http://doi.org/10.4078/jrd.2013.20.3.172

Abstract

Cytomegalovirus (CMV) is a relatively common viral pathogen, and CMV infection is generally assumed asymptomatic in general hosts. In immunologically compromised patients, CMV infection can cause further serious diseases such as pneumonitis, retinitis, encephalitis, and enterocolitis. A 40-year-old man is being presented with acute fever, myalgia, and sore throat. Laboratory findings have revealed elevated ESR, CRP, and ferritin levels. The patient was being treated for adult-onset Still's disease (AOSD). Three weeks later, although AOSD activity was under control, the patient began to complain about oral soreness, epigastric pain, and diarrhea. Endoscopy revealed multiple round ulcers with white patches in the esophagus and the stomach, sparing the colon. Anti-fungal agent is being administered but failed to bring improvements after 2 weeks of therapy. CMV infection is confirmed with pathology, antiviral agents were initiated after the ulcers subsided. Currently, clinical associations between CMV infection and AOSD are suggested. CMV infection may be considered as a differential diagnosis when multiple upper gastrointestinal ulcerative lesions develop within patients whom have been treated AOSD with immunosuppressive agents.

Keyword

Cytomegalovirus; CMV; Gastric ulcer; Adult onset Still's disease; AOSD

MeSH Terms

Antiviral Agents
Colon
Cytomegalovirus
Cytomegalovirus Infections
Diagnosis, Differential
Diarrhea
Encephalitis
Endoscopy
Enterocolitis
Esophagus
Ferritins
Fever
Humans
Immunosuppressive Agents
Pharyngitis
Pneumonia
Retinitis
Still's Disease, Adult-Onset
Stomach
Stomach Ulcer
Ulcer
Antiviral Agents
Ferritins
Immunosuppressive Agents

Figure

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  Figure 1. Gastrointestinal tract endoscopic findings. Multiple whitish plaques are observed in esophagus (A), variable-sized multiple superficial ulcers and erosions are shown in gastric antrum (B), and relatively normal-appearing colonic mucosa is shown (C).

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  Figure 2. Microscopic findings of specimen obtained from gastrofibroscopic biopsy. The fibroblasts and endothelial cells show the intra-nuclear and cytoplasmic inclusions (arrow), and perinuclear halo (arrowhead), characteristic of cytomegalovirus infection (H&E stain, ×400).

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  Figure 3. Followup of gastrofi-broscopy in six months. Whitish patches (A) and ulcerative lesions disappeared. Mild gastric erosive lesions remained (B).

Reference

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