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1/175. Misdiagnosis of specific cytomegalovirus infection of the ileoanal pouch as refractory idiopathic chronic pouchitis: report of two cases.

    PURPOSE: Chronic nonspecific reservoir ileitis (pouchitis) occurs in 5 to 10 percent of patients who undergo ileal pouch-anal anastomosis for ulcerative colitis. Specific infection of the ileal pouch-anal anastomosis with cytomegalovirus has not been reported. AIM: We report two patients with specific cytomegalovirus infection of the ileal pouch-anal anastomosis, initially misdiagnosed as idiopathic chronic pouchitis. CASE SERIES: Patient 1 had ileal pouch-anal anastomosis for ulcerative colitis. Three years later she had diarrhea, fever, pelvic pain, and pouch inflammation at endoscopy consistent with pouchitis. She had no response to medical therapy. Repeat endoscopy showed persistent inflammation and biopsies showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 10 mg/kg/day for ten days (stopped for rash). Repeat pouch biopsies were negative for cytomegalovirus. Patient 2 had ileal pouch-anal anastomosis for ulcerative colitis. Nine years later she had resection of obstructing stricture at previous loop ileostomy site. She underwent reoperation with ileostomy and pouch defunctionalization for peritonitis. Four weeks later she had fever and bloody discharge from the diverted pouch. Pouch endoscopy with biopsy showed inflammation consistent with pouchitis. She had no response to medical therapy. Re-examination of pouch biopsies with a specific monoclonal immunofluorescent stain showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 10 mg/kg/day for 21 days. Repeat pouch biopsies were negative for cytomegalovirus. CONCLUSIONS: Specific cytomegalovirus infection of the ileal pouch-anal anastomosis may be misdiagnosed as idiopathic refractory chronic pouchitis. cytomegalovirus must be excluded before immune modifier therapy or pouch excision in these patients.
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2/175. cytomegalovirus colitis in the immunocompetent host: an overview.

    This paper describes 2 immunocompetent patients with cytomegalovirus colitis and reviews all previously reported cases (n = 13). Affected patients were generally older (69.13 /-15.62 y-old) with probable reactivation (n = 8) or younger (43.86 /-19.73 y-old) with probable primary infection (n = 7). The onset of illness was found to be hospital-associated in 4 (50.0%) reactivation cases and 1 (14.3%) primary case. Presenting manifestations included diarrhoea (86.7%), fever (80.0%), gastrointestinal bleeding (66.7%) and abdominal pain (60.0%). endoscopy showed erosive colitis with multiple (n = 11; 73.3%) or single ulcers (n = 2, 13.3%); biopsy was diagnostic in 12/13 (92.3%) patients. Complications included massive haemorrhage (13.3%), toxic megacolon (13.3%), perforation (13.3%) and protracted inflammatory bowel disease (20.0%; exclusively in primary-infection). The mortality rate was 26.7%. Antiviral-agents were given in 8 (53.3%) cases; assessment of treatment-efficacy was not possible. In conclusion, cytomegalovirus colitis in the immunocompetent-host is a rare but potentially severe erosive disease with significant morbidity. It may occur during primary infection or reactivation; the diagnosis requires careful histopathological examination and the benefit of antiviral-therapy is unknown.
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3/175. De novo hemolytic uremic syndrome postrenal transplant after cytomegalovirus infection.

    After renal transplantation, hemolytic uremic syndrome (HUS) may occur as recurrent disease or de novo. Here, we describe the de novo occurrence of HUS immediately after the onset of primary cytomegalovirus (CMV) disease in two renal allograft recipients. Patient no. 1 had primary CMV disease with biopsy-proven CMV esophagitis 2 months after transplantation. Patient no. 2 experienced primary CMV disease with fever and leukopenia 8 years after transplantation. Both patients were treated with intravenous ganciclovir. Both patients developed HUS with biopsy-proven thrombotic microangiopathy in the renal allograft only a few days (3 to 5 days) after the onset of CMV disease. The short interval between the onset of CMV disease and HUS, as well as the parallel course of CMV viremia and HUS in both patients, indicate there may be a pathophysiological link between both diseases. However, because antiviral therapy with ganciclovir was started before the onset of HUS in both patients, we cannot definitely rule out that HUS was triggered by ganciclovir.
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4/175. Fatal herpesvirus-6 encephalitis in a recipient of a T-cell-depleted peripheral blood stem cell transplant from a 3-loci mismatched related donor.

    Human herpesvirus-6 (HHV-6), like all the other herpes viruses, remains latent in host cells after primary infection but can be reactivated in immunocompromised patients causing fever, skin rash, bone marrow (BM) suppression, pneumonitis, sinusitis and meningoencephalitis. We describe the case of a man with chronic myelogenous leukemia who developed encephalitis associated with acute graft-versus-host disease two months after a T-cell-depleted mismatched peripheral blood stem cell transplant. Magnetic resonance images of the brain revealed multiple bilateral foci of signal abnormality. HHV-6 was the only pathogen detected in cerebrospinal fluid by PCR. Treatment with both ganciclovir and foscarnet was unsuccessful and the patient gradually deteriorated and died. Other cases of HHV-6 encephalitis after bone marrow transplantation are reviewed.
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5/175. Disseminated cytomegalovirus disease in a patient with systemic lupus erythematosus not undergoing immunosuppressive therapy.

    We describe a case of cytomegalovirus (CMV) infection in a 25-year-old woman with a 3-year history of systemic lupus erythematosus (SLE) with persistently high disease activity, who had not received immunosuppressive therapy. Disseminated CMV infection presented with upper gastrointestinal bleeding, high fever, respiratory distress, leukopenia, and thrombocytopenia. The CMV infection was successfully treated with combined antiviral and immunoglobulin therapy, and the SLE activity decreased concomitantly. CMV disease is closely related to host immunosuppression, primarily T-lymphocyte dysfunction. This case should highlight the relationship between clinically significant CMV disease and compromised immunity in patients with active SLE who are not receiving immunosuppressive therapy.
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6/175. polyarteritis nodosa and cytomegalovirus: diagnosis by polymerase chain reaction.

    We investigated the occurrence of an active cytomegalovirus (CMV) infection in patients with polyarteritis nodosa (PAN). Eleven patients with PAN were screened for the presence of CMV-dna in their blood using the polymerase chain reaction (PCR). serum anti-CMV IgG and anti-CMV IgM antibodies were determined by enzyme-linked immunosorbent assays (ELISA). The ELISA for IgM was negative in all cases whereas that for IgG was positive in eight cases. Only one patient was positive for CMV-dna by PCR. He presented with myalgia, polyarthralgia, fever and weight loss, suggesting PAN activity. CMV infection was uncommon in our series of patients with PAN, despite disease activity and immunosuppressor therapy. The finding of a transient CMV infection in one case at the beginning of PAN activity suggests that CMV may be involved in the pathogenesis of PAN.
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7/175. polymyositis associated with primary cytomegalovirus infection.

    A case of polymyositis associated with primary cytomegalovirus infection in a 17-y-old girl is reported. The girl exhibited fever, sore throat, progressive myalgia and muscle weakness with elevated creatine kinase, atypical lymphocytosis and myopathic features in the electromyogram. Histopathologically, biopsied muscle met the criteria for polymyositis. Primary cytomegalovirus infection was proven by seroconversion of IgG as well as IgM antibodies. This is the first report of an association between cytomegalovirus infection and polymyositis.
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8/175. cytomegalovirus pericarditis with cardiac tamponade in a young infant.

    The principal viruses implicated in pericarditis are enteroviruses. cytomegalovirus pericarditis is quite rare and has been reported in immunocompromised patients with acquired immunodeficiency syndrome, malignant neoplasm or organ transplantation. We report a three-month-old male infant who suffered from cough and rhinorrhea for two weeks. He developed shortness of breath for three days, and fever for one day, prior to admission. physical examination revealed tachycardia, tachypnea, pale conjunctiva, hepatomegaly, and a muffled heart sound without significant murmur. Chest radiography showed marked enlargement of the cardiac silhouette. echocardiography demonstrated a large amount of pericardial effusion with impaired diastolic ventricular function. After pericardial drainage and supportive treatment, the fluid gradually disappeared. Viral culture of the pericardial fluid and serologic data confirmed a cytomegalovirus infection. cytomegalovirus pericarditis should be included in the differential diagnosis of pericardial effusion in a young infant.
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9/175. Ileal perforation caused by cytomegalovirus infection in a critically ill adult.

    cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract is common and is most often seen in patients with acquired immunodeficiency syndrome (AIDS), inflammatory bowel disease, or those receiving immunosuppressive therapy. CMV infection of the small bowel accounts for only 4.3% of all CMV infections of the GI tract. Isolated cases of small bowel perforation due to CMV have been reported in AIDS patients, and all but one patient has died. This article reports the first case of an ileal perforation due to transfusion-associated CMV infection in a critically-injured non-AIDS patient. Immediate surgical resection and antiviral therapy led to complete recovery. The development of abdominal pain, fever, watery diarrhea, and GI bleeding in a critically ill patient should prompt the clinician to consider the diagnosis of CMV enteritis. If standard stool pathogens and clostridium difficile toxin studies are nondiagnostic, endoscopic evaluation and CMV serology should be obtained. If CMV infection is confirmed, ganciclovir therapy should be initiated without delay. If bowel perforation occurs. prompt surgical resection is indicated. A heightened level of suspicion for CMV infection in multiply injured trauma victims and other critically ill patients, with earlier recognition of potential small bowel involvement, can hopefully decrease the incidence of bowel perforation, which is usually a fatal event.
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10/175. hemoperitoneum due to acute cytomegalovirus infection in a patient receiving peritoneal dialysis.

    A 27-year-old man receiving continuous ambulatory peritoneal dialysis (CAPD) developed high-grade fever, dyspnea, and hemoperitoneum 32 months after the start of CAPD. A chest computed tomograph showed fine reticular shadows in the bilateral lower lung fields. cytomegalovirus (CMV) antigenemia were detected, and immunoglobulin (Ig) M and IgG antibodies for CMV were also positive. The absolute counts of helper T cells (478/microL) and the ratio of helper T cells/suppressor T cells (0.25) decreased, despite no evidence of hematologic or immunologic diseases, including human immunodeficiency virus (hiv) or human T cell lymphoma virus-1 (HTLV-1) infection, or the use of immunosuppressive drugs. All symptoms, including hemoperitoneum and the ratio of helper T cells/suppressor T cells, improved gradually and spontaneously. Acute and primary cytomegalovirus (CMV) infection induced hemoperitoneum in a patient who was receiving CAPD.
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