Cytomegalovirus Esophagitis

What is Cytomegalovirus Esophagitis?

Cytomegalovirus (CMV) is a type of herpes virus, the largest of its kind. It is transmitted through body fluids during birth or sexual contact. Although any person can be infected, it potentially causes serious illnesses mainly in people with weakened immune systems. This includes patients with AIDS, those who’ve undergone organ transplants, and individuals undergoing chemotherapy.

CMV can affect different parts of the body like the eyes, stomach, colon, and esophagus. However, our focus is on its impact on the esophagus. CMV esophagitis, inflammation of the esophagus due to CMV, is the second most common gut-related issue caused by this virus. The most common symptom of CMV esophagitis is painful or difficulty swallowing, often due to large sores in the mid to lower parts of the esophagus.

Diagnosis usually involves a biopsy and pathological confirmation. Treatment generally involves antiviral medicines, but researchers are currently searching for alternative treatments. Despite the existing treatment options, CMV infection of the esophagus often has a poor outcome, with high chances of recurring and resulting in significant health issues within a year.

What Causes Cytomegalovirus Esophagitis?

CMV, or Cytomegalovirus, is a type of virus that’s part of the herpes family. This virus can be caught at birth or later on in life through sexual contact. People who have weakened immune systems are at the highest risk of developing the active disease. This includes those with AIDS, people who have had organ transplants or bone marrow transplants, and individuals who are undergoing treatment for cancer that weakens the immune system.

There have been very few cases of CMV affecting the esophagus in people who have a fully functioning immune system. In many cases, people who get infected with CMV don’t show any symptoms – this makes CMV one of the most common human viral infections.

If you do catch CMV, the virus stays in your body for life. This means that there’s always the chance that the virus can become active again intermittently.

Risk Factors and Frequency for Cytomegalovirus Esophagitis

CMV, or cytomegalovirus, is a virus that is frequently found in adults, with anywhere from 40 to 100 percent of the adult population being affected. It’s also quite common globally, with about 70 percent of people worldwide carrying the latent CMV infection. It’s particularly prevalent among different socioeconomic statuses, ethnicities and regions. This virus notably impacts people with AIDS, and it’s their most frequent viral opportunistic infection. Within the body, CMV commonly affects the gastrointestinal tract. Specifically, it most often occurs in the colon, followed by the esophagus.

• CMV affects 40 to 100 percent of adults.
• About 70 percent of people worldwide have latent CMV infections.
• The presence of CMV often relates to socioeconomic status, ethnicity, and geographic region.
• For the AIDS population, CMV is the most common viral opportunistic infection.
• Within the body, CMV mainly affects the colon and the esophagus.

Signs and Symptoms of Cytomegalovirus Esophagitis

Cytomegalovirus (CMV) is a type of virus that can cause infection. However, in most healthy people, this virus doesn’t lead to any symptoms or only causes a mild illness, similar to the symptoms of mononucleosis. This typically happens because most people have been infected at some point, but the virus only becomes active in certain situations. It generally becomes a problem in people who have a weak immune system. This includes patients with AIDS, particularly when their CD4 cell count decreases dramatically, and people who have received organ transplants.

One of the most common symptoms of an active CMV disease is a large, painful ulcer in the far end of the food pipe. This symptom is often seen in patients with AIDS and those who received organ transplants. These individuals will usually feel pain while swallowing, constant chest pain beneath the breastbone, and might even have difficulty swallowing. But, keep in mind that people can experience multiple ulcers as well.

• Pain while swallowing
• Constant chest pain beneath the breastbone
• Difficulty swallowing (sometimes)

Other symptoms can include:

• Nausea
• Vomiting
• Stomach pain
• Weight loss
• Diarrhea

In rare cases, the disease can cause bleeding in the digestive system and narrowing of the food pipe.

Testing for Cytomegalovirus Esophagitis

Many non-invasive methods are available to diagnose cytomegalovirus (CMV) infection. However, endoscopy (examining the person’s insides with a small camera) and biopsy (taking a small piece of tissue for analysis) are still the most reliable tests. The presence of CMV in tissue or body fluids doesn’t always mean that the person has the CMV disease, since in healthy people, CMV can exist but not show any symptoms.

Blood tests that look for anti-CMV antibodies don’t really help in diagnosis. These tests reveal if a person was infected recently (indicated by the presence of anti-CMV IgM) or if they’ve had a previous infection (shown by anti-CMV IgG). However, the disease is usually linked to defects in part of the immune system (cell-mediated immunity) that these tests don’t evaluate.

Blood and throat cultures can pinpoint those at risk of developing the disease. However, these tests might not accurately identify active disease, particularly in high-risk populations such as organ transplant recipients.

The endoscopic observation of CMV infection in the esophagus can show specific types of ulcers. These are usually well-defined, shallow, vertically or horizontally oriented sores found in the middle to lower parts of the esophagus. There can be one or several ulcers, which can be deep, similar to cavities. Additionally, the areas surrounding these ulcers may show signs like swelling or small, rounded protrusions.

Establishing a definitive diagnosis of CMV disease requires finding cells that have been altered by the CMV, which contain specific CMV features. This often depends on having a sufficient amount of tissue samples and a diligent pathologist to inspect them. Immunohistochemistry, a process that labels specific CMV substances in the tissues, can be helpful when these altered cells are hard to find, but it usually isn’t used as an initial test.

Treatment Options for Cytomegalovirus Esophagitis

Ganciclovir and valganciclovir are the primary treatment for CMV esophagitis. Typically, an aggressive initial treatment phase, called “induction therapy”, is started with ganciclovir. This drug is given intravenously at a specific dose (10-15 mg/kg) divided into 2-3 doses per day, for 3 to 6 weeks, depending on the patient’s situation.

After the initial phase, a “maintenance therapy” with a lower daily dose of ganciclovir is carried out. This is important in cases where there are other issues like eye disease (retinitis) or recurring issues with the patient’s digestive system after stopping the initial treatment.

Sadly, it’s quite common for the disease to come back. This is because the patients typically have a persistent severe immune deficiency, meaning their immune system is always weakened. The treatment helps control the infection, but can’t completely eradicate it. If the disease reoccurs, the initial treatment or “induction” should be repeated, followed by the maintenance therapy.

If ganciclovir doesn’t work or the virus becomes resistant to it, another drug called Foscarnet can be used. If the disease doesn’t respond to one drug alone (“monotherapy”), combining intravenous ganciclovir and foscarnet can also be tried.

What else can Cytomegalovirus Esophagitis be?

Cytomegalovirus esophagitis, a condition that affects the esophagus, often shows up as one large, isolated sore in the lower part of the esophagus. Sometimes, it can appear as a more widespread inflamed esophagus. Identifying this condition can be tricky since it can look like other issues such as herpes simplex virus (HSV) esophagitis and acid peptic disease.

However, there are small differences that set them apart. For instance, HSV esophagitis usually shows up as multiple, small, shallow sores rather than one large one. Also, HSV esophagitis generally affects the whole esophagus, whereas cytomegalovirus esophagitis often impacts the middle to the lower part of the esophagus.

Doctors also need to rule out other conditions that can cause similar symptoms. These conditions can include:

• Achalasia (a problem with the throat that makes it hard to swallow)
• Acid peptic disease (stomach acid damaging the digestive tract)
• Aphthous ulcers (canker sores)
• Barrett esophagus and Barrett ulcer (a condition where the esophagus is damaged by stomach acid)
• Candidiasis (a fungal infection)
• Cryptococcosis (a fungal infection)
• Drug-induced dysphagia (trouble swallowing caused by medication)
• Epstein-Barr virus infection (that causes mononucleosis)
• Esophageal cancer
• Gastroesophageal reflux disease (stomach acid backing up into the esophagus)
• Herpes simplex esophagitis (sores in the esophagus caused by herpes virus)
• Histoplasmosis (a fungal infection)
• Tuberculosis (a bacterial lung infection)

What to expect with Cytomegalovirus Esophagitis

Upper gastrointestinal CMV disease in individuals with weak immune systems can lead to serious health issues and even death, with some studies showing a mortality rate as high as 25% within a year. The largest case study of this disease in people without HIV but with weakened immune systems showed that nearly 28% of participants passed away within a year of being diagnosed.

The risk of death within a year increases if a person has more than one risk factor. These risk factors include naturally weak immune systems, a history of transplantation, active cancer, low white blood cell count due to immune-suppressing drugs, recent use of systemic steroids, or immune-suppressing drugs, or chemotherapy.

There is some hope, though. In some cases, where the cause of the weak immune system can be reversed – like by stopping the use of steroids, cancer chemotherapy drugs, or other immune-suppressing drugs – patients may overcome their CMV disease.

For those with stronger immune systems, where this disease is self-limiting, the use of supportive therapy, like using medication to ease symptoms without directly addressing the cause, can help with symptom relief and there’s typically no poor outcome to worry about.

Possible Complications When Diagnosed with Cytomegalovirus Esophagitis

Malnutrition can occur if a person finds it painful or hard to swallow, and this can be particularly harmful in serious illnesses like AIDS or when an organ failure requires a transplant. When ulcerations or wounds become too deep and widespread, two very critical scenarios might occur – spontaneous rupture of the wound or heavy bleeding from the gastrointestinal tract (the tract from our mouth to anus). These can also happen during medical procedures like endoscopy.

Though not very common, the formation of strictures or abnormal narrowing has been seen even after treatments with specific antiviral medicines such as ganciclovir and foscarnet. Strictures can show up as the first symptom of CMV esophagitis (infection in the food pipe due to a virus called CMV) even without prior ulcers. In one instance, a stricture grew to a point where it completely blocked the food pipe. This happened in a patient who had actually finished antiviral treatment and pathology samples taken after the treatment didn’t even show CMV or another virus HSV.

This clearly shows that strictures can form despite treatment and recovery from the disease.

Preventing Cytomegalovirus Esophagitis

The CMV virus (Cytomegalovirus) can infect a vast number of people and stay dormant in their bodies, even if their immune systems are weak. People with healthy immune systems don’t typically show symptoms. However, certain categories of patients – like those undergoing chemotherapy, older adults, newborn babies, AIDS patients, and organ transplant recipients – are at a higher risk of getting this virus.

CMV can be transmitted through contact with infected bodily fluids. This can occur during childbirth, exposure to infected blood products, or through sexual contact.

If a person suspects they have CMV, they should discuss their symptoms with the doctor in charge of their respective treatment. For instance, AIDS patients would talk to infectious disease specialists, autoimmune disease patients would consult with rheumatologists, and patients on chemotherapy would reach out to oncologists. Usually, these patients would also need to see a gastroenterologist, a stomach and digestive system specialist, for an upper endoscopy with biopsy. A biopsy is a procedure where a small sample of tissue is taken for testing. The biopsy samples will be examined by pathologists who will then establish the final diagnosis.

There are antiviral medications such as ganciclovir, valganciclovir, and foscarnet that can help control the infection. However, it’s worth noting that CMV can remain dormant in the body and possibly reactivate in the future.