1. Relationship between CMV & PU disease
Dr. Monem Alshok Noor Sami Abood
Department of Medicine , MSc , Microbiology
College of Medicine , Babylon University

2. Gastrointestinal CMV disease is an increasingly recognized clinical problem that occurs in various settings characterized by impaired host immunity. It should be suspected when patients with abnormal immune function develop symptoms and signs of gastrointestinal mucosal ulceration, which is the major macroscopic feature of CMV gastrointestinal disease

3. A diagnosis of CMV in immunodeficient patients can be confirmed by identifying cytomegalic cells in mucosal biopsy specimens of gastrointestinal lesions. The pathologist can also identify CMV using special stains for viral markers. Although many questions about dose, duration, maintenance, complications of therapy, and the indications for maintenance therapy are unanswered, treatment with ganciclovir or foscarnet can heal gastrointestinal CMV lesions. Future research should be directed toward developing effective CMV prophylactic treatment in immunosuppressed patients at high risk for CMV disease. In addition, more sensitive diagnostic techniques and more effective and less toxic therapies are urgently needed

4. . Endoscopic gastric mucosal biopsy specimen from an AIDS patient with severe CMV infection

5. Three endoscopic photographs of gastrointestinal cytomegalovirus disease
colon
esophagus
stomach

6. Gastrointestinal CMV disease is an erosive or ulcerative process that can occur at any location in the gastrointestinal tract, from mouth to rectum. Cytomegalovirus infection of columnar epithelial cells, endothelial cells, myocytes, and fibroblasts causes tissue destruction and ulceration. Serious CMV disease most frequently occurs with immune deficiency, such as the acquired immunodeficiency syndrome, after organ transplantation, after cancer chemotherapy, and after steroid therapy. Symptoms and signs depend on which part of the gastrointestinal tract is involved. Diagnosis depends on a positive mucosal biopsy that shows the presence of CMV by histopathologic or other techniques. In patients with persistent immune deficiency, progressive intestinal disease and death are frequent. Treatment with ganciclovir or foscarnet often heals intestinal lesions

7. Methods Used To Diagnose Gastrointestinal Cytomegalovirus Disease

8. Patient & Methods:-
100 patients with PU disease & 50 control subjects were studied over a period of one year , in order to detect any relationship between PU disease and presence of CMV infection . The age of the patients ( 16 – 70 ) years with a mean age of 38 , and 76 were males and 24 females . Of the 100 patients with PU , there were 77 DU patients & 23 are GU . Blood samples were taken from the control & patients and tested by using ELISA techniques for presence of Anti – CMV antibodies IgG & IgM types . Antral biopsies were taken from 38 patients and the material was tested using H & E stain and Fluorescent techniques in order to dectect the presence of giant cells and specific virus inclusion bodies in the tested biopsy specimens

9. Results :
The study shows that all patients with PU disease have detectable antibodies ( anti – CMV ab . IgG ) in their serum and only 11 have significantly detectable IgM Anti – CMV ab. . No one of the control group demonstrate a detectable IgM Anti – CMV ab. In their serum & only 6 out of 50 control group have detectable IgG antibodies . All biopsy samples from patients with PU disease show positive giant cells & inclusion bodies .

10. Conclusions:
( 1 ) Internists should be aware of the various clinical settings and locations in the gastrointestinal tract in which CMV disease occurs. Patients with immune deficiency and gastrointestinal signs and symptoms should have imaging tests and mucosal biopsies to investigate the possibility of CMV intestinal disease. Treatment with antiviral chemotherapy improves outcome in many patients

11. ( 2 ) Cytomegalovirus (CMV) is a common human viral infection, affecting 40% to 100% of adults. Acute infections are frequently asymptomatic, but once the infection is acquired, there is lifelong latency coupled with the risk for intermittent reactivation. Although gastrointestinal CMV disease can occur in persons with normal immune function, it most frequently occurs in adults with immune deficiency, such as the acquired immunodeficiency syndrome (AIDS), organ transplantation, cancer chemotherapy, and steroid therapy. Because the number of patients with immune deficiency has increased dramatically in recent years, and because CMV is one of the most common infectious complications in these settings, the number of patients with CMV disease is also increasing. New diagnostic tests and treatments have been developed to help physicians address this growing problem

12. ( 3 ) Cytomegalovirus can damage many organs, including the lung, retina, liver, and gastrointestinal tract. This review describes the pathogenesis of gastrointestinal CMV disease, the types and locations of gastrointestinal lesions, the clinical settings in which they occur, and the specific methods available to diagnose and treat the disease. Cytomegalovirus infection of the liver and pancreas will not be discussed.

13. ( 4 ) A descriptive study published in 1964 suggested that CMV may cause gastrointestinal disease in patients without detectable immunodeficiency . Immunocompetent patients have developed gastrointestinal CMV disease associated with community-acquired, acute primary CMV infection , blood transfusions , or sexual transmission . Several authors have reported an acute, self-limited gastropathy in children, associated with marked hypertrophy of gastric folds and protein-losing enteropathy. These patients had serologic, histologic, or culture evidence of CMV infection, or all three.

14. In Conclusion , the study shows significant relationship between CMV infection & PU disease and this needs further future follow up & investigations .

15. Thank you