Ann Surg Treat Res.  2023 Feb;104(2):119-125. 10.4174/astr.2023.104.2.119.

Emergency gastrointestinal tract operation associated with cytomegalovirus infection

• Kim S
• Yoon KW
• Gil E
• Yoo K
• Choi KJ
• Park CM

• KMID: 2539226
• DOI: http://doi.org/10.4174/astr.2023.104.2.119

Abstract

Purpose
Cytomegalovirus (CMV) infection is common in immunocompromised patients. Enterocolitis caused by CMV infection can lead to perforation and bleeding of the gastrointestinal (GI) tract, which requires emergency operation. We investigated the demographics and outcomes of patients who underwent emergency operation for CMV infection of the GI tract.
Methods
This retrospective study was conducted between January 2010 and December 2020. Patients who underwent emergency GI operation and were diagnosed with CMV infection through a pathologic examination of the surgical specimen were included. The diagnosis was confirmed using immunohistochemical staining and evaluated by experienced pathologists.
Results
A total of 27 patients who underwent operation for CMV infection were included, 18 of whom were male with a median age of 63 years. Twenty-two patients were in an immunocompromised state. Colon (37.0%) and small bowel (37.0%) were the most infected organs. CMV antigenemia testing was performed in 19 patients; 13 of whom showed positive results. The time to diagnose CMV infection from operation and time to start ganciclovir treatment were median of 9 days. The reoperation rate was 22.2% and perforation was the most common cause of reoperation. In-hospital mortality rate was 25.9%.
Conclusion
CMV infection in the GI tract causes severe effects, such as hemorrhage or perforation, in immunocompromised patients. When these outcomes are observed in immunocompromised patients, suspicion of CMV infection and further evaluation for CMV detection in tissue specimens is required for proper treatment.

Keyword

Cytomegalovirus; Gastrointestinal tract; Immunocompromised host

Figure

• 

  Fig. 1 The flowchart of patient selection. GI, gastrointestinal; CMV, cytomegalovirus.

• 

  Fig. 2 The number of patients who underwent emergency gastrointestinal operation due to cytomegalovirus infection by year.

Reference

1. Park SC, Jeen YM, Jeen YT. Approach to cytomegalovirus infections in patients with ulcerative colitis. Korean J Intern Med. 2017; 32:383–392. PMID: 28490715.

2. Ozaki T, Yamashita H, Kaneko S, Yorifuji H, Takahashi H, Ueda Y, et al. Cytomegalovirus disease of the upper gastrointestinal tract in patients with rheumatic diseases: a case series and literature review. Clin Rheumatol. 2013; 32:1683–1690. PMID: 23942768.

3. Seo M, Kim DH, Gong EJ, Ahn JY, Lee JH, Jung KW, et al. Is follow-up endoscopy necessary in upper gastrointestinal cytomegalovirus disease? Medicine (Baltimore). 2016; 95:e3389. PMID: 27175637.

4. Marques S, Carmo J, Pinto D, Bispo M, Ramos S, Chagas C. Cytomegalovirus disease of the upper gastrointestinal tract: a 10-year retrospective study. GE Port J Gastroenterol. 2017; 24:262–268. PMID: 29255766.

5. Maiorana A, Baccarini P, Foroni M, Bellini N, Giusti F. Human cytomegalovirus infection of the gastrointestinal tract in apparently immunocompetent patients. Hum Pathol. 2003; 34:1331–1336. PMID: 14691920.

6. Mohanlal RD, Karstaedt A. Cytomegalovirus infection of the gastrointestinal tract in Soweto, South Africa: A look back at the clinical and histological features over 8 years. J Infect Dis Epidemiol. 2017; 3:038.

7. Tachikawa Y, Nozawa H, Tanaka J, Nishikawa T, Tanaka T, Kiyomatsu T, et al. Colonic perforation in a patient with systemic lupus erythematosus accompanied by cytomegalovirus infection: a case report. Int J Surg Case Rep. 2016; 23:70–73. PMID: 27093690.

8. Toogood GJ, Gillespie PH, Gujral S, Warren BF, Roake JA, Gray DW, et al. Cytomegalovirus infection and colonic perforation in renal transplant patients. Transpl Int. 1996; 9:248–251. PMID: 8723195.

9. Chamberlain RS, Atkins S, Saini N, White JC. Ileal perforation caused by cytomegalovirus infection in a critically ill adult. J Clin Gastroenterol. 2000; 30:432–435. PMID: 10875475.

10. Wexner SD, Smithy WB, Trillo C, Hopkins BS, Dailey TH. Emergency colectomy for cytomegalovirus ileocolitis in patients with the acquired immune deficiency syndrome. Dis Colon Rectum. 1988; 31:755–761. PMID: 2844477.

11. O’Hara KM, Pontrelli G, Kunstel KL. An introduction to gastrointestinal tract CMV disease. JAAPA. 2017; 30:48–52.

12. You DM, Johnson MD. Cytomegalovirus infection and the gastrointestinal tract. Curr Gastroenterol Rep. 2012; 14:334–342. PMID: 22588614.

13. Kambham N, Vij R, Cartwright CA, Longacre T. Cytomegalovirus infection in steroid-refractory ulcerative colitis: a case-control study. Am J Surg Pathol. 2004; 28:365–373. PMID: 15104299.

14. Juric-Sekhar G, Upton MP, Swanson PE, Westerhoff M. Cytomegalovirus (CMV) in gastrointestinal mucosal biopsies: should a pathologist perform CMV immunohistochemistry if the clinician requests it? Hum Pathol. 2017; 60:11–15. PMID: 27666768.

15. Goodman ZD, Boitnott JK, Yardley JH. Perforation of the colon associated with cytomegalovirus infection. Dig Dis Sci. 1979; 24:376–380. PMID: 222560.

16. Michalopoulos N, Triantafillopoulou K, Beretouli E, Laskou S, Papavramidis TS, Pliakos I, et al. Small bowel perforation due to CMV enteritis infection in an HIV-positive patient. BMC Res Notes. 2013; 6:45. PMID: 23379792.

17. Kram HB, Hino ST, Cohen RE, DeSantis SA, Shoemaker WC. Spontaneous colonic perforation secondary to cytomegalovirus in a patient with acquired immune deficiency syndrome. Crit Care Med. 1984; 12:469–471. PMID: 6325091.

18. Montoya JG, Giraldo LF, Efron B, Stinson EB, Gamberg P, Hunt S, et al. Infectious complications among 620 consecutive heart transplant patients at Stanford University Medical Center. Clin Infect Dis. 2001; 33:629–640. PMID: 11486285.

19. Francis ND, Boylston AW, Roberts AH, Parkin JM, Pinching AJ. Cytomegalovirus infection in gastrointestinal tracts of patients infected with HIV-1 or AIDS. J Clin Pathol. 1989; 42:1055–1064. PMID: 2555397.

20. Bernard S, Germi R, Lupo J, Laverriere MH, Masse V, Morand P, et al. Symptomatic cytomegalovirus gastrointestinal infection with positive quantitative real-time PCR findings in apparently immunocompetent patients: a case series. Clin Microbiol Infect. 2015; 21:1121.e1–1121.e7.

21. Cha JM, Lee JI, Choe JW, Joo KR, Jung SW, Shin HP, et al. Cytomegalovirus enteritis causing ileal perforation in an elderly immunocompetent individual. Yonsei Med J. 2010; 51:279–283. PMID: 20191024.

22. Wreghitt TG, Teare EL, Sule O, Devi R, Rice P. Cytomegalovirus infection in immunocompetent patients. Clin Infect Dis. 2003; 37:1603–1606. PMID: 14689339.

23. Karakozis S, Gongora E, Caceres M, Brun E, Cook JW. Life-threatening cytomegalovirus colitis in the immunocompetent patient: report of a case and review of the literature. Dis Colon Rectum. 2001; 44:1716–1720. PMID: 11711750.

24. Nasa M, Mishra SR, Lipi L, Sud R. Common variable immunodeficiency syndrome with chronic diarrhoea. BMJ Case Rep. 2019; 12:e228240.

25. Patra S, Samal SC, Chacko A, Mathan VI, Mathan MM. Cytomegalovirus infection of the human gastrointestinal tract. J Gastroenterol Hepatol. 1999; 14:973–976. PMID: 10530492.

26. Le PH, Lin WR, Kuo CJ, Wu RC, Hsu JT, Su MY, et al. Clinical characteristics of cytomegalovirus colitis: a 15-year experience from a tertiary reference center. Ther Clin Risk Manag. 2017; 13:1585–1593. PMID: 29290686.

27. Rafailidis PI, Mourtzoukou EG, Varbobitis IC, Falagas ME. Severe cytomegalovirus infection in apparently immunocompetent patients: a systematic review. Virol J. 2008; 5:47. PMID: 18371229.

28. Tan KK, Bang SL, Sim R. Surgery for small bowel perforation in an Asian population: predictors of morbidity and mortality. J Gastrointest Surg. 2010; 14:493–499. PMID: 19997984.

29. Badgwell BD, Camp ER, Feig B, Wolff RA, Eng C, Ellis LM, et al. Management of bevacizumab-associated bowel perforation: a case series and review of the literature. Ann Oncol. 2008; 19:577–582. PMID: 18024857.

30. Lankaram J. A study of small bowel perforations [thesis]. Madurai Medical College;2006.