Cytomegalovirus esophagitis with symptoms of gastroesophageal reflux disease in a kidney transplant recipient

Abstract

Gastrointestinal (GI) cytomegalovirus (CMV) disease is a critical factor in the management of immunocompromised patients. 1 The esophagus has been reported as the second most common GI organ associated with CMV infection. 2 Documented scenarios associated with this complication include human immunodeficiency virus infection, transplantation, chemoradiotherapy, and corticosteroid use. 2–4 Although odynophagia, dysphagia, and retrosternal pain are typical symptoms reported by patients with CMV esophagitis, nonspecific symptoms including nausea, vomiting, fever, abdominal pain, and weight loss may also be associated with this disease. 3 To the best of our knowledge, this is the first report of a kidney transplant recipient who was incidentally diagnosed with CMV esophagitis during evaluation for underlying gastroesophageal reflux disease (GERD). Laboratory data included: blood urea nitrogen, 35.6 mg/dL; creatinine, 1.19 mg/dL; hemoglobin, 11.6 g/dL; red blood cell count, 3.75 × 106 cells/μL; and white blood cell count, 9.1 × 103 cells/μL (segmented polymorphonuclear leukocytes, 86%; and lymphocytes, 9%). F, Five months after the initiation of antiviral therapy, EGD findings were consistent with complete resolution of CMV esophagitis The patient was treated with oral valganciclovir (900 mg/day) for 21 days together with a proton pump inhibitor for 56 days.

Gastrointestinal (GI) cytomegalovirus (CMV) disease is a critical factor in the management of immunocompromised patients.¹ The esophagus has been reported as the second most common GI organ associated with CMV infection.² Documented scenarios associated with this complication include human immunodeficiency virus infection, transplantation, chemoradiotherapy, and corticosteroid use.^2–4 Although odynophagia, dysphagia, and retrosternal pain are typical symptoms reported by patients with CMV esophagitis, nonspecific symptoms including nausea, vomiting, fever, abdominal pain, and weight loss may also be associated with this disease.³ To the best of our knowledge, this is the first report of a kidney transplant recipient who was incidentally diagnosed with CMV esophagitis during evaluation for underlying gastroesophageal reflux disease (GERD).

A 55‐year‐old woman with chronic GERD treated with sucralfate received a deceased‐donor kidney transplant. Six weeks later, she experienced acid reflux‐like discomfort alone which was similar to her earlier GERD symptoms; the symptoms persisted for several days. She did not experience other symptoms such as dysphagia, odynophagia, retrosternal/abdominal pain, and nausea. Laboratory data included: blood urea nitrogen, 35.6 mg/dL; creatinine, 1.19 mg/dL; hemoglobin, 11.6 g/dL; red blood cell count, 3.75 × 10⁶ cells/μL; and white blood cell count, 9.1 × 10³ cells/μL (segmented polymorphonuclear leukocytes, 86%; and lymphocytes, 9%). The patient underwent an esophagogastroduodenoscopy (EGD) on posttransplant day 55 that revealed multiple linear esophageal ulcers between 25 and 35 cm (Figure 1A) and a mucosal break of >5 mm near the squamocolumnar junction corresponding Los Angeles grade B reflux esophagitis (Figure 1B). CMV‐infected cells with inclusion bodies were identified within the ulcers (Figure 1C). Immunohistochemistry with anti‐CMV CCH2 confirmed the diagnosis of CMV esophagitis (Figure 1D).

1 FIGURE. Esophagogastroduodenoscopy (EGD) was performed on day 55 after kidney transplant to evaluate symptoms suggestive of gastroesophageal reflux disease (GERD). A, Multiple linear esophageal ulcers between levels of 25 and 35 cm were identified. B, One mucosal break >5 mm in length was identified near the squamocolumnar junction corresponding to Los Angeles grade B reflux esophagitis. C, Cytomegalovirus (CMV)‐infected cells with inclusion bodies were detected within the linear ulcers (arrows; Hematoxylin & Eosin stain, ×400). D, Immunohistochemistry confirmed the diagnosis of CMV esophagitis (CCH2 stain, ×400). E, Two months after the initiation of 21‐day antiviral therapy, a follow‐up EGD revealed one small focal erosive lesion only (arrowhead), with healing of the previous ulcers. F, Five months after the initiation of antiviral therapy, EGD findings were consistent with complete resolution of CMV esophagitis

The patient was treated with oral valganciclovir (900 mg/day) for 21 days together with a proton pump inhibitor for 56 days. EGD after treatment revealed only a small focal erosion; the ulcers and mucosal break had healed (Figure 1E). No evidence of CMV infection was found on biopsy. Complete recovery was confirmed 3 months later via both EGD (Figure 1F) and tissue pathology.

Of importance, CMV immunoglobulin (Ig) tests were performed for both donor and recipient prior to the transplant procedure.⁵ Similar results, including reactive IgG (500 AU/mL) and nonreactive IgM (index = 0.75), were detected postoperatively in the recipient who was prior to initiation of immunosuppressants (tacrolimus 12 mg/day and mycophenolate mofetil 1000 mg/day). Three weeks after discharge (<2 weeks prior to presentation), anti‐CMV titers remained stable, including IgG at 469.4 AU/mL and IgM at 0.67. Negative results were obtained from CMV‐DNA polymerase chain reaction. As such, if had there been no symptoms of GERD, we might not have diagnosed CMV infection in this patient as she did not have typical symptoms or serum findings.

The unique case highlights three key points with respect to the management of immunocompromised patients: (1) one cannot rule out CMV infection simply by symptoms or serum tests, (2) regular follow‐up is critical even among those who are asymptomatic, and (3) further examination is critical if latent infection is suspected.

ACKNOWLEDGMENT

Thanks for all the colleagues of Department of Gastroenterology and Hepatology of Linkou Chang Gung Memorial Hospital to help us caring the patient and collecting the data.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.