Enteritis and Severe Abdominal Pain as the First Presentation of Covid-19.

Presentation A male patient with no significant past medical history presented to emergency department with progressive in severity abdominal pain, associated with mild nausea and diarrhea. No other significant symptoms were reported. Diagnosis On investigation with CT, duodenojejunitis was diagnosed as the cause of abdominal pain. Lung basal changes were also visualized and subsequently proven to be secondary to Covid-19 infection. Treatment After few days of hospitalization and supportive treatment, the patient improved clinically and was discharged. Conclusion Covid-19 infection typically presents with respiratory symptoms associated with fever and myalgia. Anorexia, diarrhea and nausea have been reported. Severe abdominal pain is rare, particularly as the initial presenting compliant. It is important to be aware of the varied clinical presentations that may occur in Covid-19, including isolated gastrointestinal symptoms. This will allow to increase the timely detectability of infected patients and more effective contact control measures.

Catastrophic gastrointestinal complication of systemic immunosuppression.

We present a case of acute upper gastrointestinal haemorrhage in a patient with systemic vasculitis immunosuppressed on cyclophosphamide and prednisolone. The patient presented with a diffuse haemorrhagic oesophagitis and a non-specific duodenitis. Biopsies taken from the oesophagus and duodenum demonstrated infection with herpes simplex virus (HSV) and cytomegalovirus (CMV) respectively. Viral infection of the upper gastrointestinal tract is a recognised complication of immunosuppression and HSV is one of the most common pathogens. CMV on the other hand most commonly causes a colitis or less commonly oesophagitis. CMV enteritis is rare as is the synchronous infection with two viral agents in an immunocompromised patient having being described in a few case series only. Viral infection of the gastrointestinal tract in immunocompromised patients should be treated with systemic anti-viral medication and consideration to withdrawal of the immunosuppressive therapy if possible and appropriate. The authors highlight the need for a high suspicion of viral infection in immunosuppressed patients presenting with upper gastrointestinal bleeding.

[The clinical significance of evaluation of the inflammatory infiltrate in chronic gastroduodenitis in children].

OBJECTIVE: To establish the diagnostic value of the determination of leukocyte composition of inflammatory infiltrate in chronic gastroduodenite in childhood. PATIENTS AND METHODS: We examined 103 patients aged 8-17 with chronic gastroduodenitis associated with Helicobacter pylori. To detect Hp and Epstein-Barr viral infections we used esophagogastroduodenoscopy, quick urease test, bacterioscopy of gastrobiopsies. We performed the analysis of the cellular composition of the inflammatory infiltrate. RESULTS: It was found that the number of lymphocytes and neutrophils located in the lamina and intraepithelial increases, which is associated with the degree of inflammation. Increased to the maximum was the number of intraepithelial lymphocytes, both in the body, and in the antrum. Intensity of leukocyte infiltration is directly correlated with the increased prevalence of inflammation. Persistence of Epstein-Barr virus (35.9% of patients) is followed by more severe intraepithelial lymphocytic infiltration in the stomach. In 4-6 months after treatment 18 patients with severe gastritis were repeatedly studied for the inflammatory infiltrate. A significant decrease in the number of intraepithelial neutrophils was found. CONCLUSION: Cellular composition of the infiltrate is an objective characteristic of chronic inflammation in the gastric mucosa. Persistence of Epstein-Barr virus is accompanied by an increase in the amount of intraepithelial lymphocytes and neutrophils.

Clinical features and treatment of ulcerative colitis-related severe gastroduodenitis and enteritis with massive bleeding after colectomy.

INTRODUCTION: Ulcerative colitis (UC) has been recognised as a systemic immune disorder that is not as restricted as colitis. UC-related gastrointestinal lesions with bleeding can develop soon after colectomy and can progress rapidly. Therefore, we considered the clinical features and treatment of these UC-related lesions. METHODS: We reviewed the patient data in our UC surgery database to evaluate its prevalence and features. RESULTS: We found 7/1,100 patients with UC-related lesions between January 2000 and April 2013. These lesions developed at a mean of 24 (range 8-480) days after colectomy. Six of the seven patients suffered from gastrointestinal bleeding as an initial symptom that rapidly developed into massive bleeding or perforations. All of the patients were diagnosed with pancolitis; at the time of colectomy, fulminant, severe, moderate, and mild colitis were presented by four, one, one, and one patients, respectively. All patients with enteritis had consecutively developed other infectious complications, including anastomotic leakage, pyoderma gangrenosum, wound infection, and pneumonia. Although patients with bleeding did not respond to treatment with corticosteroids, they responded well to infliximab soon after its administration. Although six of the seven patients showed cytomegalo virus re-activation in blood or pathological examinations, ganciclovir was not effective in its elimination. CONCLUSION: Although UC-related lesions with an unknown aetiology can occur after colectomy, immediate examination and treatment are required if gastrointestinal bleeding is found after surgery. Because gastrointestinal bleeding from UC-related lesions can worsen rapidly and may be related to mortality, early potent immunosuppressive therapy should be considered.

[Cycloferon therapy of chronic gastroduodenitis in children].

The efficiency of immunomodulating therapy with cycloferon in children aged from 10 to 16 years with verified chronic gastroduodenitis was estimated. It was shown that the cycloferon treatment provided reliable increase of T- and B-cellular populations in mucous membranes of the stomach and duodenum, normalization of the number of CD8-lymphocytes, higher titers of IgG antibodies to herpes viruses 1 and 2. It also promoted reduction of inflammation in the mucous membranes along with reduction of the disease clinical signs.

[Features of mucosal lesions of stomach and duodenum in children with chronic gastroduodenitis with different microflora content].

OBJECTIVE: Our aim was to reveale the features of histological mucosa with different composition of the microflora of stomach and duodenum in children with chronic gastroduodenitis. METHODS: The study included 122 children with chronic gastroduodenitis from 5 to 17 years old. All patients underwent endoscopy with histology of biopsy specimens of gastric and duodenal mucosa in 94 patients and in 48 patients among them with morphometry of biological material. Identification of herpes simplex virus 1, 2 types, cytomegalovirus, human papilloma virus 16, 18 types, Helicobacterpylori was carried out using polymerase chain reaction in biopsies of gastroduodenal mucosa and gastric juice. RESULTS: Children with chronic gastroduodenitis depending on the identified microorganisms were divided into groups: 1st (n = 51)--without detectable microorganisms, 2nd (n = 28)--with associations of H. pylori and viruses, 3rd (n = 15)--only with viruses, 4th (n = 28)--with H. pylori. Thus, in patients with H. pylori inflammation was noted mainly in the antral mucosa and dystrophic changes--in the duodenal mucosa. In the presence of viruses the inflammation was expressed more in the fundal stomach and duodenum. When viral-bacterial associations were observed most pronounced inflammatory-dystrophic process was localized throughout the gastroduodenal mucosa. CONCLUSION: In children with chronic gastroduodenitis in the presence of bacterial, viral and mixed microflora in the stomach and duodenum identified characteristic histological features of the mucosa, manifested in a different localization and severity of inflammatory and dystrophic changes.

[A case of cytomegalovirus gastroduodenitis in an immunocompetent adult].

A 58-year-old male developed epigastric discomfort and high fever in 2010. Complete blood count showed leukocytosis and a small number of atypical lymphocytes. Gastric endoscopy revealed multiple gastroduodenal erosions and ulcers. Biopsy specimens were obtained and pathological examination demonstrated cytomegalic inclusion bodies. Cytomegalovirus (CMV) IgM antibody was positive and CMV DNA was detected with PCR in his blood, leading to the diagnosis of CMV gastroduodenitis. He was treated with intravenous ganciclovir and his symptoms resolved rapidly. It is recognized that CMV gastroduodenitis is extremely rare in immunocompetent hosts but sometimes shows a severe clinical course in elderly patients. The results from our present patient suggest that we should consider CMV infection in the differential diagnosis of multiple gastroduodenal erosions and ulcers. Our data also suggested that anti-CMV medications could be important treatment options for CMV gastroduodenitis, especially in elderly patients.

[Evaluation of the effectiveness of immunomodulating therapy in children with chronic gastroduodenitis].

The article assesses the effectiveness of administering immunomodulating drug cycloferon in patients aged 10 to 16 years with chronic gastroduodenitis. It is established that the use of cycloferon in children with virus-associated chronic gastroduodenitis leads to a significant increase in T- and B-lymphocyte populations in mucous membranes of the stomach and duodenum, and contributes to the elimination of viruses. This results in reduced severity and activity of inflammation in the mucous membranes and decreases clinical manifestations of the disease.

[Relationship of gastric microflora and neopterin content in gastric juice in children with chronic gastroduodenitis].

The study included 71 children with chronic gastroduodenitis aged 5-17 years. PCR DNA was determined by the presence of Helicobacter pylori, human papilloma virus high cancer risk 16, 18 types (HPV), herpes simplex 1 and type 2 (HSV), cytomegalovirus (CMV), fungi, Candida in gastric juice and biopsy specimens of gastric mucosa and duodenal. Viruses were detected in 14% of patients, an association of microorganisms - in 20% of the children, the isolated H. pylori infection - 18%. The relationship between the composition of microflora in the gastroduodenal region and neopterin levels in gastric juice with a distinct increase in its value in the presence of viruses.

[Is antiviral therapy in gastroduodenal pathology necessary?].

Mucous membrane of the gastroduodenal region of 104 patients with different pathologies (gastritis and erosive ulcerative alterations) was investigated by polymerase chain reaction (PCR). Examination of the biopsy material revealed frequent occurrence of pathogenic strains of Helicobacter pylori (up to 80%) and Herpesviridae (EBV, HHV 6, HHV 7, HHV 8) in various combinations. In such cases it is necessary to use adequate antibacterial and antiviral therapy with individual choice of immunomodulators.

[Morphological characteristics of duodenum mucosa in children with atopic dermatitis].

The results of investigation of 87 children suffering from chronic gastroduodenitis and atopic dermatitis are presented. All the child underwent fibrogastroduodenoscopy with duodenal mucosal biopsy and diagnostics of Helicobacter pylori infection, lambliasis. Hystomorphological and immunohystochemical studies of mucosal biopsy specimens for Epstein - Barr virus were carried out. The role of atopy and infection factors in genesis of chronic gastroduodenitis was evaluated.

[Chronic gastroduodenitis in children with atopic dermatitis].

The results of investigation of 49 children suffering from chronic gastroduodenitis and atopic dermatitis are presented. All the child underwent serological blood analyses for Epsteine-Barr virus antibodies and fibrogastroduodenoscopy with antral and duodenal mucosal biopsy. Hystomorphological and immunohystochemical studies of mucosal biopsy specimens for Epsteine-Barr virus were carried out. The role of Epsteine-Barr virus in genesis of chronic gastroduodenitis is detected.

A case of acute gastroduodenitis with cytomegalovirus infection in a healthy adult.

A 33-year-old man with epigastralgia was admitted. Upper gastrointestinal endoscopy revealed gastric fold hypertrophy, mucosal hemorrhage, and widespread erosion in the stomach and aphthoid erosion in the duodenum. The presence of intranuclear inclusion bodies positively stained with anti-cytomegalovirus antibody from the biopsy specimens indicated that the gastroduodenitis was related to cytomegalovirus (CMV) infection. He recovered within 2 weeks without antiviral therapy. Duodenal involvement of CMV infection is fairly rare in immunocompetent hosts.

Endoscopic diagnosis of cytomegalovirus infection of upper gastrointestinal tract in solid organ transplant recipients: Hungarian single-center experience.

BACKGROUND: Cytomegalovirus (CMV) is considered to be the major cause of upper gastrointestinal (GI) symptoms in organ transplant recipients. In the diagnosis of GI CMV infection the detection of the virus in the mucosa is essential. The aim of the study was to evaluate the significance of CMV, detected in biopsy specimens from stomach and duodenum of solid organ transplant recipients. METHODS: Data of 227 elective upper endoscopies on symptomatic organ transplant recipients were evaluated for clinical symptoms, endoscopic changes and conventional histologic alterations of mucosal biopsy samples. Qualitative PCR was performed for detection of the presence of CMV-DNA in each biopsy materials. RESULTS: CMV-DNA was detected in biopsy samples of 91 patients (40.1%) while only in 20 cases (8.8%) the signs of CMV infections were found by conventional histology (p < 0.00001). No considerable differences could be observed in symptomatic, histologic alterations between CMV-PCR positive and negative groups. There were no endoscopic changes in 25.3% of CMV-PCR positive and 5.1% of negative patients. CONCLUSIONS: Qualitative PCR is an accurate method for the detection of CMV in the mucosa of the GI tract. Further investigations are needed for determination of the exact pathological role of detected CMV.

Successful treatment of Good syndrome with cytomegalovirus duodenoenteritis using a combination of ganciclovir and immunoglobulin with high anti-cytomegalovirus antibody titer.

We describe the case of a 64-year-old woman with Good syndrome who presented with watery diarrhea and abdominal distention caused by cytomegalovirus (CMV) duodenoenteritis. Thymoma and hypogammaglobulinemia were first identified when the patient was 58 years old. She had repeatedly complained of symptoms even after thymectomy. Abdominal radiography revealed multiple air-fluid levels, and computed tomography revealed ascites and dilation of the small intestine. Immunofluorescent staining of specimens obtained by duodenal mucosal biopsy revealed intracellular inclusion bodies of CMV, although serum CMV pp65 antigenemia assays yielded negative results. CMV infection of the small intestine caused mucosal edema resulting in malabsorption. The patient was treated using ganciclovir and an immunoglobulin preparation with a high titer of antibodies against CMV (CMV-Ig), and subsequently made a rapid recovery from abdominal symptoms. When patients with Good syndrome complain of abdominal symptoms, particularly chronic diarrhea, a diagnosis of CMV gastroenteritis should not be excluded, even if negative results are obtained for CMV pp65 antigenemia assays. Combination therapy of ganciclovir and CMV-Ig seems useful for patients with CMV gastroenteritis.

Herpesvirus 6 variant A infection after heart transplantation with giant cell transformation in bile ductular and gastroduodenal epithelium.

Herpesvirus 6 (HHV-6) is a ubiquitous virus known to cause febrile syndromes and exanthema subitum in children. Less commonly, and particularly in organ transplant recipients, it may result in hepatitis, bone marrow suppression, interstitial pneunonitis, and meningoencephalitis. This report expands the spectrum of clinical disease associated with HHV-6 by documenting viral infection in a 44-year-old heart transplant recipient presenting with gastroduodenitis, pancreatitis, and hepatitis. On histopathologic examination, the gastric, duodenal, and bile ductular epithelium showed a multinucleate giant cell transformation similar to the cytopathic effect caused by the virus in human T-lymphocytes infected in vitro. Electron microscopy showed herpes particles with a thick tegument layer in the duodenum. Polymerase chain reaction amplified HHV-6 variant A sequences from multiple sites. Serology confirmed the presence of an acute HHV-6 infection. Thus, HHV-6 variant A can cause gastroduodenitis and pancreatitis in immunosuppressed individuals. Multinucleate giant cells and enveloped virions with a prominent tegument can be used as morphologic criteria to raise the possibility of HHV-6 infection in human biopsy tissue.