Surgical manifestations of gastrointestinal cytomegalovirus infection in children: Clinical audit and literature review.
BACKGROUND
Gastrointestinal sequelae of cytomegalovirus are rare, usually associated with significant immune compromise, and carry a high morbidity and mortality. Gastrointestinal disease frequently requires surgical intervention for diagnosis and management.


OBJECTIVE
The aim of the study is to evaluate the incidence, presentation and management of gastrointestinal cytomegalovirus disease in a pediatric population.


METHODS
Between January 2003 and June 2011, a retrospective folder review was conducted of all symptomatic children with proven CMV disease, presenting to the surgical service. Eligible patients were identified using the surgical, histopathology and serology databases.


RESULTS
Thirty-eight patients (1.8/1000 surgical admissions) were identified with a median presenting age of 5months (range 3days-12years). Esophagitis (n=18) and small bowel disease (n=16) predominated, but CMV was seen throughout the gastrointestinal tract. Risk factors included HIV infection (n=21, 55%) and recent gastrointestinal surgery or infection (n=10, 26%). Characteristic multiple jejunoileal perforations were seen in six patients. Compared to upper GIT disease, intestinal involvement was associated with younger age and doubled mortality. In HIV-infected children, median CD4 (%) was lower in intestinal compared to upper gastrointestinal disease. Morbidities included anastomotic breakdowns (5), anastomotic strictures (3), relook laparotomies (10), resistant esophageal strictures (5) and prolonged parenteral nutrition (5). Anti-CMV drugs were given in 63%. Overall mortality was 32% (12/38) and was associated with lower GIT disease.


CONCLUSIONS
Invasive CMV gastrointestinal disease in our children was predominantly HIV-associated, or followed a major lower gastrointestinal inflammatory insult in infants younger than 6months. Successful therapy requires a high index of suspicion of active CMV disease to allow early implementation of CMV viral load control and aggressive treatment of the underlying immune impairment. Multiple surgical interventions are often required for both tissue diagnosis and management of acute and chronic complications. CMV-viral-load-tailored anti-CMV therapy is supported by recent literature.
Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
M
M
Arnold
Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
R
R
Itzikowitz
Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
B
B
Young
Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
S M
SM
Machoki
Division of Medical Virology, National Health Laboratory Service/University of Cape Town, Cape Town, South Africa.
N Y
NY
Hsiao
Department of Histopathology, NHLS, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
K
K
Pillay
Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
A
A
Alexander
D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D054869:Clinical Audit; D003587:Cytomegalovirus; D003586:Cytomegalovirus Infections / Q000150:complications* / Q000453:epidemiology / Q000628:therapy*; D013505:Digestive System Surgical Procedures; D005260:Female; D005767:Gastrointestinal Diseases / Q000453:epidemiology / Q000628:therapy* / Q000821:virology*; D015658:HIV Infections / Q000150:complications; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors
Cytomegalovirus (CMV); Enteritis; Gastrointestinal disease; Intestinal perforation; Oesophageal stricture; Oesophagitis; Paediatric