Catastrophic gastrointestinal complication of systemic immunosuppression

Abstract

We present a case of acute upper gastrointestinal haemorrhage in a patient with systemic vasculitis immunosuppressed on cyclophosphamide and prednisolone. The patient presented with a diffuse haemorrhagic oesophagitis and a non-specific duodenitis. Biopsies taken from the oesophagus and duodenum demonstrated infection with herpes simplex virus (HSV) and cytomegalovirus (CMV) respectively. Viral infection of the upper gastrointestinal tract is a recognised complication of immunosuppression and HSV is one of the most common pathogens. CMV on the other hand most commonly causes a colitis or less commonly oesophagitis. CMV enteritis is rare as is the synchronous infection with two viral agents in an immunocompromised patient having being described in a few case series only. Viral infection of the gastrointestinal tract in immunocompromised patients should be treated with systemic anti-viral medication and consideration to withdrawal of the immunosuppressive therapy if possible and appropriate. The authors highlight the need for a high suspicion of viral infection in immunosuppressed patients presenting with upper gastrointestinal bleeding.

Treatment and management of CMV duodenitis in a patient with temporal arteritis

“…CMV infection could be very severe in geriatric patients (4,5). Such infections by CMV in those with a compromised immune system are usually treated with systemic antiviral therapy and if needed withdrawal of the immune suppressive drugs (2). This was also shown by Onaka et al, who demonstrated the effectiveness of intravenus ganciclovir to treat CMV gastroduodenitis (4).…”

“…Virus transmission occurs through blood products, the placenta, sexual contact, organ transplantation or breast milk. CMVs involvement of the GI system usually leads to a ulcerative lesion, with CMV gastritis presenting as abdominal pain and hematemesis while CMV colitis (CMV's main manifestation of the GI system) presenting as diarrhea in an infected individual (2,3). Infections by CMV are also considered when a patient has more than one ulcer and various erosions in the gastroduodenal region (4).…”

Herpes Simplex Virus Esophagitis in the Setting of Acute Use of Corticosteroids for COPD Exacerbation in an Immunocompetent Middle-Aged Woman

“…Herpes esophagitis usually self-resolves in immunocompetent patients [ 10 ]; few case reports show empiric treatment with valacyclovir. The use of antiviral is still controversial in this case.…”

Cytomegalovirus Proctitis in a Patient with Chronic Lymphocytic Leukemia on Ibrutinib Therapy: A Case Report

“…CMV is a latent herpes virus infection that can undergo reactivation in an immunosuppressed host, leading to an increased risk of mortality and morbidity [5,6,9]. Therefore, early diagnosis and initiation of antiviral therapy are crucial for improved outcomes [5,9,10]. Patients with hematological neoplasms have impaired T-cell function, which increases their risk of CMV reactivation [9].…”

“…However, ibrutinib has been associated with several opportunistic infections, especially in the first 6-12 months of initiation of therapy [3,4]. Cytomegalovirus (CMV) is an opportunistic infection of immunosuppressed hosts due to T-cell dysfunction that occurs due to chronic antigen stimulation in the setting of latent viral infection or underlying cancer [1,[5][6][7]. Gastrointestinal (GI) CMV infection is more pronounced in this patient population and leads to increased overall morbidity and mortality [6,8].…”