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Archives of Clinical Microbiology
1989-8436
2022
1
© Under License of Creative Commons Attribution 3.0 License |
Research Article
It Medical Team
https://www.itmedicalteam.pl/
Gasterointesnal Tract Infecons
With Human Cytomegalovirus And
Mycobacterium Tubercolusis
Alireza Mohebbi1*,
Fahimeh Azadi2, Touba
Ghorbanzadeh3, Shabnam
Naderifar4
1 Laboratory Sciences Research Center,
Golestan University of Medical Sciences,
Gorgan, Iran
2 Department of Microbiology, School of
Medicine, Golestan University of Medical
Sciences, 4934174515, Gorgan, Iran
3 Department of Microbiology, Tehran
North Branch, Islamic Azad University of
Tehran, 1111743765, Tehran, Iran
4 Department of Microbiology, Karaj
Branch, Islamic Azad University,
1451685645, Karaj, Iran
Corresponding author:
Alireza Mohebbi
Mohebbi-a@goums.ac.ir
Tel: +98 935 467 4593
Department of Microbiology, School of
Medicine, Golestan University of Medical
Sciences, 4934174515, Gorgan, Iran
Citaon: Mohebbi A, Azadi F, Ghorbanzadeh
T, et al. (2022) Gasterointesnal Tract
Infecons With Human Cytomegalovirus
And Mycobacterium Tubercolusis. Arch
Introducon
Gastrointesnal (GI) diseases encompass complicaons ranging
from the mouth to the anus. GI includes esophageal, stomach,
intesne, liver, pancreas, gallbladder, and biliary tract ailments.
Common manifestaons of GI disorders include epigastric
pains or tenderness and distenon, gastrointesnal bleeding,
intesnal obstrucon, and malabsorpon [1,2]. Infecous agents
can also aect GI tract inammaon or gastris [3]. H. pylori-
associated gastris is the most common cause of gastris in the
world. Several other H. pylori-negave gastris is autoimmune
gastris [3], gastris due to infecous agents Mycobacterium
tuberculosis (M. tuberculosis) [4], Cytomegalovirus (MCV) [3],
Herpes Simplex virus (HSV) [6], radiaon gastris, collagenous
gastris, eosinophilic gastris, Sarcoidosis-associated gastris,
lymphocyc gastris, Ischemic gastris, Crohn disease-associated
gastris, vasculis-associated gastris, and Ménétrier disease [7].
In parcular, CMV infecon occurs almost only in
immunocompromised paents, especially in transplant
recipients. CMV infecon in immunocompetent paents is
usually asymptomac or, if symptomac, most commonly causes
a mononucleosis-like syndrome [8]. CMV can aect any organ in
these paents, with the most common site of infecon being the
Abstract
Gastrointesnal (GI) diseases due to infecous agents Mycobacterium tuberculosis
and Human Cytomegalovirus (HMCV) in immunocompetent paents are usually
asymptomac and are related to rare cases of GI complicaons. The present study
reviews the most prevalent clinical ndings and GI tract symptoms of CMV and
TB cases for a beer prognosis and therapeuc approaches. Epigastric pain or
tenderness is the most reported symptom in paents with HCMV infecon of the
GI tract. Paents may develop a fever in some cases with antrum ulcers (~39°C).
Edema is also reported in young adults and children, mainly depicted on the
feet or face. Similarly, epigastric pain is the main symptom observed in paents
with gastric TB. Weight loss due to decreased appete, nausea, and voming
in TB paents was also reported. The diagnosis of gastric CMV and TB could be
symptomac. Clinical ndings, including posive an-CMV IgM and endoscopic
enlarged gastric folds and high liver enzymes with hypo (proteinemia) albuminemia,
can be the indicaons of gastric CMV in immunocompetent paents. Addionally,
a posive PCR of acid-fast bacilli and endoscopy of necroc epithelial cells can
be the signs of gastric TB. Gastric infecon can lead to further complicaons and
gastric cancer, which increases the disease's burden and cost and lengthens the
period of treatment. The clinical ndings and symptoms of gastris caused by
CMV and TB are reported in this paper. Understanding gastris infecons might
improve the clinical outcome of the condion by allowing beer prognosis and
earlier therapeuc intervenons.
Keywords: Gastris; Gastrointesnal tract infecon; Human Cytomegalovirus;
Mycobacterium tuberculosis; Prognosis
Received: 02-July-2022, Manuscript No. ipacm-22-12662; Editor assigned: 04-July-2022, Pre-
qc No. ipacm-22-12662 (PQ); Reviewed: 19-July-2022, QC No. ipacm-22-12662 (Q) Revised: 25-
july-2022, Manuscript No. ipacm-22-12662 (R); Published: 30-July-2022, DOI: 10.36648/1989-
8436X.22.13.7.193
Vol. 13 No. 7: 193
Clinic Microbio, Vol. 13 No. 7: 193.
2022
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Archives of Clinical Microbiology
1989-8436
gastrointesnal tract. CMV disease of the GI tract is dened by
infecon and the presence of macroscopic pathological features
or signicant GI symptoms [9]. Endoscopic features associated
with gastric CMV infecon, including ulcers and erosions, were
observed in most cases [10]. In the diagnosis of CMV-associated
GI infecon, it is crucial to detect the presence of the virus in the
mucosa of the upper GI tract. In addion, CMV serology can help
disnguish primary infecon from CMV reacvaon.
In the case of TB, the most common form of the disease is
the pulmonary form, and involvement of other organs is less
common. However, it is vital that in immunosuppressed paents,
such as those infected with human immunodeciency virus (HIV),
the risk of coinfecon CMV with TB in the gastrointesnal tract
increases due to immune system defect [11,12]. Gastrointesnal
tuberculosis can be caused by the entry of infected respiratory
tract secreons into the abdomen and cause granulomatous
inammaon. Diagnosing abdominal tuberculosis can be
challenging because it can be confused with other abdominal
diseases such as malignancy and inammatory bowel disease.
The most common symptoms include weight loss followed by
abdominal pain, sweats, and fever. The most common site of
involvement in the abdomen was the lymph nodes and then
the peritoneum. TB can be acvated in infected people under
such circumstances that the immune system is disrupted, and
coinfecon CMV with TB can also lead to serious damages in
infected people [13]. According to available data, paents with
TB are more likely to become infected with CMV. Also, CMV
can cause TB acvity in infected individuals. In addion to lung
involvement, tuberculosis can aect other body parts, especially
when co-infected with CMV [14].
Developing a new model using the clinical ndings and symptoms
could be helpful for clinicians to predict rare cases of gastric CMV
and TB infecons. Therefore, this review summarizes the previous
reports of GI infecons with CMV and TB to discriminate against
both infecons.
GI infecon of HCMV
Human Cytomegalovirus (HCMV) is a DNA virus belonging to
the Herpesviridae family. CMV has been increasingly recognized
as an important common pathogen in an immunocompromised
state [15], including individuals with AIDS and organ transplant
recipients [16,17]. An increased number of cases of gastrointesnal
diseases caused by HCMV infecon has been reported (18,19).
The colon and stomach are the most common sites of GI infecon
(20), and CMV infecon of GI is rare, especially in those with
normal immunity.
CMV might infect epithelial cells of the GI tract by infected body
uid through an unknown mechanism. Symptoms of CMV-
associated gastric disease are varied. In the immunocompetent
paents, diarrhea was reported as the most common symptom
along with other common symptoms, including weight loss, fever,
hematochezia, dysphagia, abdominal distension, and abdominal
pain (8). Several case reports were invesgated in this review to
idenfy specic CMV-associated symptoms (Table 1). The ndings
show that epigastric pain or tenderness is the most reported
symptom in paents with HCMV infecon of the GI tract. It could
also lead to weight loss and voming due to decreased appete
in paents with CMV-iduced gastric ulcers, which, if remained
untreated, might be accompanied by anorexia and nausea (Table 1).
In some cases with antrum ulcers, paents may suer from fever
(~39 °C). One of the important symptoms in paents with CMV
infecon is decreased movement acvity. Edema is also reported
in younger adults and children, mainly represented on feet or
face (Figure 1).
Clinical ndings can give a good prognosis for CMV infecon
in paents referred with GI tract complicaons. CMV in
immunocompetent paents is rare, and its dierenaon
requires a quick and comprehensive intervenon, like endoscopic,
immunohistochemical, serological, and biochemical processes.
The endoscopy address the involvement of GI tract infecon,
including enlarged gastric fold, ulcers (mainly in antrum and furus),
and surface mucosal erosions. Thickness or enlarged gastric folds
was the main endoscopic nding in CMV posive GI tract infecon
paents. Addionally, there are several ways to detect CMV
infecon based on the stage of the disease. Serological methods
are used in cases in which an increased ter of IgM anbodies
indicates acve infecon. In the case of CMV infecon, especially
in immunosuppressed paents, IgM seroconversion can indicate
CMV reacvaon that is accompanied by IgG seroposivity.
Serologically, however, an-CMV IgG or IgM or both could be
observed in immunocompetent paents.
Further methods of HCMV detecon are Cytomegalovirus
angenemia for diagnosing the infecon in its early stages and
histology and observing an intranuclear cytomegalic Owl’s eye
inclusion bodies. Further ndings of CMV infecon of the GI tract
Author Year Study Country Case Coinfecons Ref.
Kim et al. 2020 Case report South Korea A 43-year-olvd woman presented with stage iii malignant melanoma - -21
Tard et al. 2019 Case report France A 7-year-old girl & a ve-and-a-half years old girl - -22
Xiong et al. 2018 Case report China A 44-year-old man - -23
Yamamoto et al. 2018 Case report Japan A 35-year-old man EBV -24
Liu et al. 2017 Case report Taiwan A 77-year-old woman - -25
Ueno et al. 2017 Case report Japan An 80-year-old woman H. pylori -26
Wang et al. 2016 Case report China A 26-year-old man H. pylori -27
Gökçe et al. 2016 Case report Turkey An 11-year-old boy, a 3-month-old boy, & a 2-month-old boy - -28
Crespo et al. 2015 Case report Portugal A 31-year-old man - -29
Baek et al. 2015 Case report South Korea An 8-year-old girl - -30
Keskar et al. 2015 Case report India A 42-year-old woman & a 32-year-old man - -31
Peixoto et al. 2013 Case report Portugal A 71 years-old man HSV-1 and EBV -32
Table 1. Case reports of CMV gastris
Vol. 13 No. 7: 193
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© Under License of Creative Commons Attribution 3.0 License
Archives of Clinical Microbiology
1989-8436
are Hypoalbuminia and hypoproteinemia, which can be observed
in both or one of each. Furthermore, in some cases, increased
liver enzymes ALT and AST have been observed.
The majority of cases of GI tract HCMV infecon paents are
asymptomac. In those cases with the symptoms menoned
above and clinical ndings, therapeuc intervenons should
be started. Acyclovir, Gancyclovir, or Valgancyclovir have been
shown to signicantly reduce the symptoms of the disease in
two or three months, and the recurrence of the disease is not
reported.
Mycobacterium tuberculosis infecon of GI tract
Tuberculosis (TB) is one of the oldest known human diseases
caused by the Mycobacterium tuberculosis (M. tuberculosis)
complex (MTBC). Despite a long history of understanding and
treang TB, it remains the most important infecous pathogen
globally and one of the ten leading causes of death worldwide.
It is reported that M. tuberculosis is responsible for 15% of
extrapulmonary infecons, which may or may not be associated
with pulmonary symptoms. Extrapulmonary infecons are
cervical lymphadenis, pleural involvement, central nervous
system (CNS) infecon, and GI infecon. GI is the sixth most
common site of extrapulmonary TB, and it is mainly associated
with pulmonary TB or immune deciencies. Furthermore, GI
infecon with TB is also reported in rare cases without evidence
of pulmonary involvement.
Gastric TB can be caused by the entry of infected respiratory
tract secreons into the abdomen and cause granulomatous
inammaon. Diagnosing abdominal tuberculosis can be
challenging because it can be confused with other abdominal
diseases such as malignancy and inammatory bowel disease.
Symptoms of gastric TB include cough, with or without fever,
diarrhea, weight loss, voming, and hematemesis. Here, we
have classied the disease symptoms of GI tract infecon with
TB according to their prevalences in several case reports (Table
2). As shown in Figure 1, epigastric pains are the main symptoms
observed in paents with GI tract infecon of TB. It also leads
to weight loss due to decreased appete, nausea, and voming
in paents with TB-induced gastric ulcers, which, if remained
untreated, might be accompanied by anorexia and conspaon.
The inamed site of infecon may also cause fever in some cases.
The clinical ndings of TB infecon of the GI tract are also varying.
(Table 2).
Endoscopically gastric TB presents frequently as a non-healing
chronic ulcer gastric perforaon, and erosions or lesions mimicking
malignancy. In addion, Nodular hypertrophic lesions sensing
the pylorus have been reported. As shown in Figure 1, caseang
granulomatous with necrosis and gastric epithelial ulcers and
inammaon of the involved ssuse are more prevalent clinical
ndings.
The diagnosis of gastric TB can be made on histopathological
examinaon, which shows caseang epithelioid cell granulomas,
the bacteriologic study of the biopsies based on acid-fast bacilli
staining or cultures to detect M. tuberculosis, and fast and accurate
polymerase chain reacon (PCR). Almost all cases of GI tract TB
infecon reported posive PCR. This implicates a sensive PCR as a
good prognosis for TB infecon in the cases of GI tract complicaons
in immunocompetent with unknown eology and history. It can also
be suggested that acid-fast staining along with PCR can be a beer
prognosis of GI tract infecon of TB than each alone.
Treatment of abdominal tuberculosis consists of two courses
of treatment; in the rst period, the paent uses four drugs of
rifampin, isoniazid, pyrazinamide, ethambutol for two months,
Figure 1 The most prevalent clinical ndings and disease
manifestaons of gastrointesnal tract infecon with
CMV and TB.
Author Year Study Country Case Coinfecons Ref.
Ma et al. 2019 Case
report China A 26-year-
old female - -45
Espinoza-Ríos 2017 Case
report Peru A 30-year-
old female HIV -44
Nayyar et al. 2016 Case
report USA A 49-year-
old female HIV -46
Ecka et al. 2013 Case
report India A 31-year-
old male - -42
Kang et al. 2012 Case
report Korea A 54-year
old female - -47
Moghadam
et al. 2012 Case
report Iran A 43-year-
old male - -48
Khan et al. 2008 Case
report Qatar A 29-year-
old man - -43
Table 2. Case reports of TB gastris.
Vol. 13 No. 7: 193
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Archives of Clinical Microbiology
1989-8436
and in the second-period paent uses two drugs of rifampin,
isoniazid for four months.
Discussion
Health care costs and burden of GI diseases are more than other
prevalent ailments rising further. Among common causes of GI
tract diseases, some opportunisc pathogens are associated
with rare cases of GI complicaons. Accurate diagnosis and
idencaon of such pathogens help to improve disease
symptoms. HCMV and M. tuberculosis are reported in several
immunocompetent paents with GI complicaons. In the present
study, the most prevalent clinical ndings and disease symptoms
of both CMV and TB cases of GI tract infecon are reviewed for
beer diagnosis and therapeuc intervenons.
Epigastric tenderness or pain is the most common symptom in
immunocompetent paents with CMV gastris. Accordingly, the
most common sites of gastrointesnal CMV infecon are the
colon and stomach. Enlarged gastric folds and ulcers are also the
most common macroscopic manifestaons of Cytomegalovirus
infecon in antrum or furus. Gastris with CMV infecon can be
diagnosed in abdominal pains, weight loss, and voming cases.
Children may also present supercial edema on their feet or
face, which is self-liming. This might be due to congenital CMV
infecons, acquired from parents with acve CMV infecon, or
reacve infecon due to immunotherapy or some illness like
Menetrier disease. However, the laer needs to invesgate
in the future. As endoscopic ndings like gastrointesnal
ulcers are dicult to nd, dierenaon tests could benet
from a seroposive IgM with or without IgG. Furthermore,
increased levels of liver enzymes along with hypo (proteinemia)
albuminemia could be the prognosis factors of gastric CMV
infecon. Furthermore, the fecal-oral transmission of CMV in
paents with posive gastric infecon remains unidened
(Figure 2).
Gastric TB is even more uncommon due to high acidity and lack
of gastric mucosal lymphoid ssue but is usually associated with
an immunodecient state, parcularly with HIV infecon. The
most common sites of TB lesions are in the antrum and prepyloric
regions. Ileocecal and jejunal regions usually include more than
60% of gastric TB cases. The clinical manifestaons of gastric
tuberculosis are nonspecic. It can be seen as a fever of unknown
origin, and it must be dierenated from Crohn's disease,
sarcoidosis, syphilis, mycoc lesions, and exposure to beryllium,
silicates, or reserpine. A posive PCR for acid-fast bacilli can be
the diagnosc tool for paents admied with epigastric pains,
weight loss, or decreased acvity, with or without fever. Acid-fast
staining can somemes show false negaves, PCR can diagnose.
A coinfecon of TB and CMV has also been reported by Stockdale
et al.,. The results of this case-control study on persons with
undiagnosed TB showed that a posive an-CMV IgG indicates
a higher risk of TB infecon. This suggests that CMV infecon
may vulnerable paents for future infecons with opportunisc
pathogens.
Conclusion
Gastrointesnal ulcers and lesions may induce anemia or, in a
worse scenario, gastric cancer, increase the burden and cost
of the disease, and in the case of infecous agents, it may also
extend the duraon of treatment. This study summarizes the
clinical ndings and symptoms of gastris with CMV and TB.
Understanding gastris infecons would enhance the clinical
outcome of disease by faster intervenons and therapy. Further
studies can expand our knowledge on the molecular basis of GI
tract infecon with CMV and TB.
Acknowledgments
Financial support for this study was provided by a grant from
the Golestan University of Medical Sciences, Gorgan, Iran with
a grant number IR.GOUMS.REC.1398.114. The authors wish to
thank the Laboratory Sciences Research Center and Department
of Microbiology of Golestan University of Medical Sciences,
the Ilamic Azad Universies of Tehran, Rasht, and Karaj, Liver
and Pancreatobiliary and Digesve Diseases Research Centers,
Sharia Hospital, Tehran University of Medical Sciences for their
spiritual supports.
Funding
A.M has received a grant (IR.GOUMS.REC.1398.114) from
Golestan University of Medical Sciences, Gorgan, Iran.
Conicts of Interest
No conicts of interest exist.
Figure 2 A schemac presentaon of GI tract infecon with CMV and
TB. Both may absorb from the upper GI tract and relocate
to a dierent part of the GI tract. However, it remains to
know whether or not they can exert from the colon.
Vol. 13 No. 7: 193
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© Under License of Creative Commons Attribution 3.0 License
Archives of Clinical Microbiology
1989-8436
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