Cytomegalovirus infection in an HIV patient with duodenal papillitis

A 52-year-old man had undergone appendectomy 2 months previously, at which time he was incidentally diagnosed with human immunodeficiency virus (HIV) infection. One month later, he revisited the hospital, complaining of vague abdominal pain with intermittent watery diarrhea. A colonoscopy was carried out, revealing multiple small ulcers in the ascending and transverse colon, biopsies from which revealed nonspecific inflammation. Two weeks later, he was hospitalized for persistent symptoms. Laboratory data demonstrated a white blood cell count of 1900/mm³ and a CD4+ lymphocyte count of 108/mm³. Chest radiography and abdominal computed tomography showed unremarkable findings. An upper endoscopy was performed. The esophagus and stomach showed unremarkable findings, but in the duodenum there was an edematous ampulla of Vater, with hyperemic mucosal changes in the second portion (Figure [1]). Histopathological examination revealed active papillitis with a few large cells infected with cytomegalovirus (CMV), confirmed by specific staining. Immunohistochemistry staining showed characteristic multiple viral inclusion bodies (Figure [2]).

Figure 1 Upper endoscopy, showing an edematous ampulla of Vater with hyperemic mucosal changes in the second portion.

Figure 2 Immunohistochemistry staining, showing the characteristic multiple cytomegalovirus inclusion bodies (original magnification × 200).

CMV infection is one of the commonest organisms in patients with acquired immune deficiency syndrome (AIDS) and frequently affects the liver and biliary tree. It is usually part of a disseminated disease. Cholestatic liver function tests have been reported in one-third of patients and radiographic evidence of sclerosing cholangitis in 3-11 % [1]. Sclerosing cholangitis, known as AIDS cholangiopathy, is associated with papillary stenosis. Endoscopic sphincterotomy is carried out in patients with papillary stenosis, with marked relief of pain in most cases [2]. In the case of the biliary tree, the viral inclusions do not always have the characteristic owl’s-eye appearance, and immunohistochemistry for CMV is extremely useful in doubtful cases [3].

Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AC

References

• 1 Jacobson M A, Cello J P, Sande M A. Cholestasis and disseminated cytomegalovirus disease in patients with the acquired immunodeficiency syndrome.  Am J Med. 1987;  84 546-549
• 2 Bonacini M. Hepatobiliary complications in patients with human immunodeficiency virus infection.  Am J Med. 1992;  92 404-411
• 3 Goldin R D, Hunt J. Biliary tract pathology in patients with AIDS.  J Clin Pathol. 1993;  46 691-693