Risk Factors, Clinical and Endoscopic Features, and Clinical Outcomes in Patients with Cytomegalovirus Esophagitis

Abstract

Cytomegalovirus (CMV) esophagitis is the second most common CMV disease of the gastrointestinal tract. This study aims to comprehensively analyze risk factors, clinical characteristics, endoscopic features, outcomes, and prognostic factors of CMV esophagitis. We retrospectively collected data of patients who underwent esophageal CMV immunohistochemistry (IHC) staining between January 2003 and April 2021 from the pathology database at the Chang Gung Memorial Hospital. Patients were divided into the CMV and non-CMV groups according to the IHC staining results. We enrolled 148 patients (44 CMV and 104 non-CMV patients). The risk factors for CMV esophagitis were male sex, immunocompromised status, and critical illness. The major clinical presentations of CMV esophagitis included epigastric pain (40.9%), fever (36.4%), odynophagia (31.8%), dysphagia (29.5%), and gastrointestinal bleeding (29.5%). Multiple diffuse variable esophageal ulcers were the most common endoscopic feature. The CMV group had a significantly higher in-hospital mortality rate (18.2% vs. 0%; p < 0.001), higher overall mortality rate (52.3% vs. 14.4%; p < 0.001), and longer admission duration (median, 24 days (interquartile range (IQR), 11−47 days) vs. 14 days (IQR, 7−24 days); p = 0.015) than the non-CMV group. Acute kidney injury (odds ratio (OR), 174.15; 95% confidence interval (CI), 1.27−23,836.21; p = 0.040) and intensive care unit admission (OR, 26.53; 95% CI 1.06−665.08; p = 0.046) were predictors of in-hospital mortality. In conclusion, the mortality rate of patients with CMV esophagitis was high. Physicians should be aware of the clinical and endoscopic characteristics of CMV esophagitis in high-risk patients for early diagnosis and treatment.

Keywords: acute kidney injury; cytomegalovirus; endoscopy; esophagitis; prognostic factor.

Figure 1

Diagnosis of CMV esophagitis using CMV IHC staining and/or CMV inclusion bodies in H&E staining. (A) H&E staining (40× objective) showing typical intranuclear (owl’s eye) and intracytoplasmic (eosinophilic punctiform) CMV inclusions within the circles. (B) IHC staining (40× objective) with 1:200 diluted Novocastra™ lyophilized mouse monoclonal antibody against CMV pp65 antigen shows strong focal CMV immunoreactivity with brownish areas. CMV—cytomegalovirus; H&E—hematoxylin and eosin; IHC—immunohistochemistry.

Figure 2

Endoscopic features of CMV esophagitis. (A) Inflammation; (B) polypoid lesion; (C–F) variable morphologies of esophageal ulcers. CMV—cytomegalovirus.

Figure 3

Kaplan–Meier survival curve analysis of patients with CMV esophagitis. (A) Patients with AKI (solid line) had a significantly worse survival rate than those without AKI (dash line) (log-rank p = 0.044). (B) Patients who required ICU care had a worse survival rate, although it was not statistically significant (log-rank p = 0.101). AKI—acute kidney injury; CMV—cytomegalovirus; ICU—intensive care unit.