LETTERS TO THE EDITOR

 

Mesenteric vein thrombosis associated with a cytomegalovirus infection

Trombosis venosa mesentérica asociada a infección por CMV

 

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Key words: Cytomegalovirus. Portal thrombosis. Mesenteric thrombosis.

Palabras clave: Citomegalovirus. Trombosis portal. Trombosis mesentérica.

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Dear Editor,

Acute cytomegalovirus (CMV) infection usually presents as mononucleosis syndrome in adolescence (1).

Mesenteric vein thrombosis has been described as a rare complication of acute CMV infection (2).

We report the case of a 66-years-old male admitted with fever and malaise of 1.5 months duration. He complained of intermittent abdominal pain and distension without altered bowel function or weight loss and an affected general status. The abdomen was soft, painful in the region of the mesogastrium without peritoneal irritation.

The blood count was within normal limits: Hemoglobin 13.5 g/dl (13-18), WBC 9.8 x 10⁹/l (3.5-10.5), platelets 312x10⁹/l (105-400). As altered parameters were: Fibrinogen 735 mg/dl (150-400), erythrocyte sedimentation rate 58 mm/h (0-10), bilirubin 1.8 mg/dl (0-1.1), conjugated bilirubin 0.8 mg/dl (0-0.4), aspartate transferase 38 U/l (0-18), and alanine transferase 33 U/l (0-22). The stool culture was negative. Computed tomography (Fig. 1) showed thrombosis of the left portal vein, the main trunk of the portal vein, splenoportal axis and the superior mesenteric vein. Serological testing for CMV showed elevated titers of IgM (95.3 IU/ml -negative < 15) and the screening for thrombophilia was negative.

 

 

With the diagnosis of portal vein thrombosis secondary to acute mesenteric CMV infection anticoagulant therapy was established for 3 months, with complete resolution in the control CT scan.

Among the inherited causes associated with portal vein thrombosis include: Mutation of factor V Leiden, mutation of prothrombin, protein C and S deficiency, antithrombin III deficiency, mutation of MTFR gene, increased factor levels VIII (3).

Venous thrombosis during acute CMV infection has a predilection for affecting the portal vein and the mesenteric territory. The exact mechanism is not well known, but there is convincing evidence of procoagulant effect in vitro of CMV (4-6). Recently, a prospective study found that CMV seropositivity was independently related to venous thrombosis, which supports the results of in vitro studies (7).

We found 19 cases of mesenteric thrombosis associated with CMV infection in the literature. The outcome was usually favorable with anticoagulant therapy for a period lasting 3 to 7 months. One had protein C and S deficiency, one was heterozygous for the factor V Leiden, two were heterozygous for G20210A factor, and seven women taking oral contraceptives. Fifteen of the nineteen had complete resolution without complications. Of these, one did not receive anticoagulant therapy. The remaining four who had consequences, had at least one risk factor for thrombosis (one protein C and S deficiency, another heterozygous prothrombin G20210A mutation, another oral contraceptives and other heterozygous for factor V Leiden). These data suggest a transient natural history of portal thrombosis with a high rate of spontaneous resolution, which is probably underestimated (8,9).

In conclusion, acute infections are associated with a transient increased risk of thromboembolic events. In all patients with thrombotic complications is indicated a screening for thrombophilia. Mesenteric thrombosis is a serious condition that involves high mortality, therefore, in all patients with CMV infection presenting abdominal symptoms should be ruled out this complication, to start anticoagulation as soon as possible (1,2).

 

Jorge Rojo-Álvaro¹, Sara Pérez-Ricarte¹,
Miren Vicuña-Arregui², Ione Villar-García¹
and Francisco Javier Anniccherico-Sánchez¹
Departments of ¹Internal Medicine and
²Digestive Diseases.
Complejo Hospitalario de Navarra.
Pamplona, Navarra. Spain

 

References

1. Aomar IF, Pérez L, Parejo MI, et al. Hepatitis aguda por citomegalovirus como causa de trombosis portal y mesentérica. Med Clin (Barc) 2010;135(7):338-9.         [ Links ]

2. Kalaitzis J, Basioukas P, Karzi E, et al. Small-bowell necrosis complicating a cytomegalovirus-induced superior mesenteric vein thrombosis in an immunocompetent patient: A case report. J Med Case Rep 2012;6:118.         [ Links ]

3. Amitrano L, Guardascione MA, Scaglione M, et al. Prognostic factors in noncirrhotic patients with splanchnic vein thromboses. Am J Gastroenterol 2007;102(11):2464-70.         [ Links ]

4. Squizzato A, Ageno W, Cattaneo A, et al. A case report and literature review of portal vein thrombosis associated with cytomegalovirus infection in immunocompetent patients. Clin Infect Dis 2007; 44(2):e13-16.         [ Links ]

5. Abquequen P, Delbos V, Ducancelle A, et al. Venous thrombosis in immunocompetent patients with acute cytomegalovirus infection: A complication may be underestimated. Clin Microbiol Infect 2010;16(7):851-4.         [ Links ]

6. Ergas D, Herskovitz P, Skurnik Y, et al. Superior mesenteric vein thrombosis with pulmonary embolism: a rare presentation of acute cytomegalovirus infection. Isr Med Assoc J 2008;10(3):235-6.         [ Links ]

7. Paran Y, Shalev V, Steinvil A, et al. Thrombosis following acute cytomegalovirus infection: A community prospective study. Ann Hematol 2013;92(7):969-74.         [ Links ]

8. Schreiner M, Barck T, Foroutan B, et al. A rare cause of portal vein thrombosis in a previously healthy young man with acute hepatitis. J Clin Virol 2011;51(3):152-4.         [ Links ]

9. Galloula A, Rossi A, Gautier V, et al. Portal vein thrombosis associated with an acute cytomegalovirus infection. J Mal Vasc 2014. doi: 10.1016/j.jmv.2014.03.005.         [ Links ]