Symptomatic cytomegalovirus gastrointestinal infection with positive quantitative real-time PCR findings in apparently immunocompetent patients: a case series

Abstract

Cytomegalovirus (CMV) gastrointestinal disease rarely occurs in immunocompetent patients, and is mainly diagnosed on the basis of histopathological findings. Real-time PCR for CMV DNA quantification is considered to be a useful diagnostic tool, but its place in the diagnostic strategy is not clearly defined. The goal of the study was to describe the clinical and paraclinical features of apparently immunocompetent patients with CMV gastrointestinal disease diagnosed according to quantitative PCR results. In this retrospective study conducted in a 1500-bed tertiary-care centre, we reviewed the case records of apparently immunocompetent patients with positive findings of CMV DNA in gastrointestinal biopsies with compatible symptoms and endoscopic findings. A total of 13 patients were included between January 2007 and December 2010. The median age was 81 years, and 54% of patients had underlying immune-modulating conditions. Diarrhoea, haematochezia and dysphagia were the main reported symptoms, and ulcers were the main endoscopic findings. The mean value of CMV DNA load in gastrointestinal biopsies was 3845 copies/μg total DNA (range, 15-15 500 copies/μg total DNA). The highest values were found in two patients who were diagnosed with adenocarcinoma in the subsequent course of CMV infection. Clinical features were similar to those in previous series in which diagnosis was based on histopathological analysis. Elderly people are more commonly affected, and a link with immune senescence is possible. Quantification of CMV DNA seems to be a useful tool for diagnosis when combined with clinical and endoscopic findings, but further studies are necessary to interpret quantitative values.

Cytomegalovirus Disease of the Upper Gastrointestinal Tract: An Emerging Infection in Immunocompetent Hosts

“…Critically ill patients, particularly those with sepsis and under mechanical ventilation, have been proposed as being at risk for this increasing incidence because of a transiently suppressed immunity [5,13] . Further, some cases in healthy individuals have also been reported [2,11,12,14,15] . Despite uncertainties about the burden of CMV disease in these patients due to few reported cases, morbidity and mortality seem to be lower than in immunocompromised patients.…”

“…Generally, this condition arises in immunocompromised patients, such as those with AIDS, patients, prophylaxis with oral valganciclovir is advocated in HIV-infected patients with a CD4+ count <50/mm 3 and CMV-negative recipients receiving an organ from CMV-positive donors [6,10] . Despite a well-established approach in immunocompromised patients, no clear guidelines have been proposed for immunocompetent patients [2,6,9] .…”

“…In immunocompromised patients, the colon is the main involved site and is associated with a high morbidity and mortality. In immunocompetent patients, CMV disease is rare even when viral shedding occurs, because cell-mediated host immune response (CD8+ cytotoxic T lymphocytes and memory T cells) prevents the development of overt CMV disease [2,5] . However, in the last decades, CMV disease in immunocompetent patients has been increasing, with more involvement of the upper gastrointestinal tract [2,7,8,10,12] .…”

“…In immunocompetent patients, CMV disease is rare even when viral shedding occurs, because cell-mediated host immune response (CD8+ cytotoxic T lymphocytes and memory T cells) prevents the development of overt CMV disease [2,5] . However, in the last decades, CMV disease in immunocompetent patients has been increasing, with more involvement of the upper gastrointestinal tract [2,7,8,10,12] . Critically ill patients, particularly those with sepsis and under mechanical ventilation, have been proposed as being at risk for this increasing incidence because of a transiently suppressed immunity [5,13] .…”

“…Cytomegalovirus (CMV) is a DNA virus belonging to the Herpesviridae family with a high seroprevalence in the general population (40-100%) [1][2][3][4] . Acute primary CMV infection usually occurs during childhood and early adolescence and has a benign course.…”