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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.105 no.1 Madrid ene. 2013

http://dx.doi.org/10.4321/S1130-01082013000100014 

LETTERS TO THE EDITOR

 

Infectious esophagic fistula: A common virus with an extraordinary presentation

Fístula esofágica infecciosa: un virus común con una presentación extraordinaria

 

 


Key words: Cytomegalovirus. Fistula. Elderly. Immunosuppression. Corticosteroids. Valganciclovir.

Palabras clave: Citomegalovirus. Fístula. Vejez. Inmnunosupresión. Corticoides. Valganciclovir.


 

 

Dear Editor,

Cytomegalovirus (CMV) is an herpesvirinae virus widely spread thorough general population, with a global prevalence between 40-100%. After primo-infection, the virus remains in latent phase and can reactivate under immunosuppression situations from different etiologies, like drug therapy -immunosuppressants (1), chemotherapy (2)- or immunodeficiencies -primary or acquired (3,4)-. CMV is a known opportunistic pathogen of the gastrointestinal tract and can cause a wide spectrum of lesions in esophagus, stomach and bowels (5).

 

Case report

We present an 88-year-old woman with polymyalgia rheumatica on treatment with oral corticosteroids (prednisone 30 mg b.i.d) who was admitted to our institution because of dysphagia, odynophagia and fatigue in the last two weeks. Some days before admission, the patient had complained of an episode of atypical thoracic pain irradiated to her neck, with a normal cardiologic study. One day after her admission she presented with hematemesis without hemodynamic instability or anemia. An upper endoscopy was performed, showing a partially fibrin-covered orifice with an apparently blind end, located in the cervical esophagus (Fig. 1A). Biopsies from the orifice borders were taken. An esophagogram and a computerized tomography scan were performed (Fig. 1B and C), showing a fistula in the lateral face of the cervical esophagus, in communication with a pseudo-cavity filled with oral contrast (esophagogram). The biopsies demonstrated the presence of the characteristic cytopathic CMV effect (Fig. 1D). After diagnosis of esophagic fistula secondary to CMV infection was established, treatment with valganciclovir (900 mg b.i.d.) was started, reducing prednisone dose. The patient experienced a significant clinical improvement in a few days. Endoscopic examination was performed 12 weeks later, and complete healing of the fistula was observed.

 

Discussion

There are scarce reports of CMV esophagic fistulae in scientific literature, usually involving a multimicrobial etiology (generally in HIV positive patients) (3,4). To our knowledge, this is the first report of esophagic fistula secondary to CMV in which the unique precipitating factor was steroids-treatment. CMV infection in immunosuppression situations must be considered in the pathogenesis of atypical digestive tract lesions, and this is not only limited to classic severe immunosuppressive settings (HIV, chemotherapy), but also possible under common treatment like steroids use.

 

Carlos Fernández-Carrillo, Alberto Herreros-de-Tejada, Clara Salas, Luis Ramos, Cristina Suárez y Luis Abreu
Hospital Universitario Puerta de Hierro Majadahonda. Madrid, Spain

 

References

1. Schooley RT, Hirsch MS, Colvin RB, Cosimi AB, Tolkoff-Rubin NE, McCluskey RT, et al. Association of herpesvirus infections with T-lymphocyte-subset alterations, glomerulopathy, and opportunistic infections after renal transplantation. N Engl J Med 1983;308:307-13.         [ Links ]

2. Sharma M, Moore J, Nguyen V, Van Besien K. Fatal CMV pneumonitis in a lymphoma patient treated with rituximab. Am J Hematol 2009;84:614-6.         [ Links ]

3. Chalasani N, Parker KM, Wilcox CM. Bronchoesophageal fistula as a complication of cytomegalovirus esophagitis in AIDS. Endoscopy 1997;29:S28-9.         [ Links ]

4. Vartian CV, Septimus EJ. Bronchoesophageal fistula due to Mycobacterium tuberculosis and cytomegalovirus in a patient with AIDS. Clin Infect Dis 1996;22:581.         [ Links ]

5. Monkemuller KE, Willcox CM. Diseases of the esophagus, stomach and bowel. In: Dolin R, Saag M, Masur H, editors. AIDS therapy. 2nd ed. Philadelphia: Churchill Livingstone; 2003. p. 885-9.         [ Links ]

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