Gut Online First, published on January 6, 2015 as 10.1136/gutjnl-2014-308851 Editor's quiz: GI snapshot
An uncommon presentation of a common pathogen QUESTION A 70-year-old woman presented with severe spasmodic abdominal pain, nausea, recurrent vomiting and mild diarrhoea. Two months earlier she underwent autologous stem cell transplantation for stage 2A follicular lymphoma. Her medical history was otherwise unremarkable. Physical examination revealed mild epigastric tenderness. Blood tests showed an elevated lactate dehydrogenase (325 IU/L; normal range 135–214 IU/L) and elevated transaminases (alanine transaminase 126 IU/L; aspartate transaminase 90 IU/L; normal range 10–35 IU/L). Blood cell counts were within the normal range. Ultrasound examination did not detect a cause for the abdominal pain. She was not on immunosuppressive therapy. Subsequently, the patient underwent upper endoscopy that revealed the presence of several protruding, ulcerative gastric lesions (ﬁgure 1A). The lesions were detected throughout the stomach while oesophagus and duodenum were spared. Biopsies of the gastric lesions were obtained for histological evaluation (ﬁgure 1B) and for microbiological analysis. Following 2 weeks of speciﬁc therapy, the gastric lesions were no longer detectable (ﬁgure 1C, D). What is the most likely diagnosis?
did not test positive for cytomegalovirus, herpes simplex virus, enteroviruses and adenoviruses. Shortly after the endoscopy, the patient developed an itching, blister-like rash as well as thrombocytopoenia of 29 000/mL. A swab test of a skin lesion was sent for virological analysis and tested positive for varicella zoster virus (VZV), and the patient was treated with 1500 mg intravenous aciclovir daily. Subsequently, the biopsies of the gastric lesions tested positive for VZV by PCR. Shortly after treatment initiation, the patient’s abdominal symptoms including nausea and abdominal pain improved notably. The mild diarrhoea persisted and was considered unrelated to the VZV infection following colonoscopy and microbiological analysis of stool samples. After 2 weeks, the ulcerative gastric lesions were no longer detectable. Instead, several mucosal scariﬁcations were observed (ﬁgure 1C, D). The patient had previously been exposed to VZV as she had tested positive for VZV-IgG prior to stem cell transplantation. In summary, the patient presented with a gastric manifestation of generalised VZV reactivation including elevated transaminases and thrombocytopoenia.1 As the infection occurred shortly after autologous stem cell transplantation, it was likely associated with an immunocompromised state of the patient. Few cases of intestinal manifestation of VZV infection have been described in the literature, especially in patients with haematological malignancies, with the stomach being the predominant localisation.2–5 Thus, intestinal VZV manifestation should be considered as a possible differential diagnosis, requiring speciﬁc virological analysis of gastric biopsies. Tobias Boettler,1 Lisa Lutz,2 Nathalie Schmidt,1 Robert Thimme,1 Christoph Neumann-Haefelin1 1
ANSWER Histological evaluation of the biopsies revealed ulceration and necrosis as well as nuclear inclusions (ﬁgure 1B). The biopsies
Department of Medicine II, University Hospital Freiburg, Freiburg, Germany Department of Pathology, University Hospital Freiburg, Freiburg, Germany
Correspondence to Dr Tobias Boettler, University Hospital Freiburg, Department of Medicine II, Hugstetter Str. 55, Freiburg D-79106, Germany; [email protected]
Contributors TB and CN-H performed the endoscopies. TB, NS, RT and CN-H made the clinical diagnosis. LL performed histological analysis. TB, RT and CN-H wrote the article. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. To cite Boettler T, Lutz L, Schmidt N, et al. Gut Published Online First: [ please include Day Month Year] doi:10.1136/gutjnl-2014-308851 Received 17 November 2014 Revised 16 December 2014 Accepted 22 December 2014 Gut 2015;0:1. doi:10.1136/gutjnl-2014-308851
REFERENCES 1 2 3 4
Tunbridge AJ, Breuer J, Jeffery KJM. Chickenpox in adults—clinical management. J Infect 2008;57:95–102. McCluggage WG, Fox JD, Baillie KE, et al. Varicella zoster gastritis in a bone marrow transplant recipient. J Clin Pathol 1994;47:1054–6. Milligan KL, Jain AK, Garrett JS, et al. Gastric ulcers due to varicella-zoster reactivation. Pediatrics 2012;130:e1377–81. Rivera-Vaquerizo PA, Gómez-Garrido J, Vicente-Gutiérrez M, et al. Varicella zoster gastritis 3 years after bone marrow transplantation for treatment of acute leukemia. Gastrointest Endosc 2001;53:809–10. Serris A, Michot JM, Fourn E, et al. [Disseminated varicella-zoster virus infection with hemorrhagic gastritis during the course of chronic lymphocytic leukemia: case report and literature review]. Rev Med Interne 2014;35:337–40.
Figure 1 (A) Endoscopic view of the stomach prior to therapy. (B) Histological picture of gastric lesion. (C) Endoscopic view of stomach following 2 weeks of therapy. (D) Histological picture of gastric scariﬁcation.
Boettler T, et al. Gut Month 2015 Vol 0 No 0
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd (& BSG) under licence.