Cytomegalovirus‐associated esophagitis on early esophageal cancer in immunocompetent host: a case report

Abstract

Background Cytomegalovirus (CMV)-associated gastrointestinal diseases usually occur in immunocompromised patients; however, few cases has also been described in healthy hosts despite still unclear pathological mechanisms. CMV esophagitis causes various lesions, such as erythematous mucosa, erosions, and ulcers, although such inflammatory changes can appear in superficial esophageal cancers or in surrounding areas. CMV-associated esophagitis has been also reported in cancer patients, but typically in those with advanced and/or terminal stage cancers secondary to chemoradiotherapy-induced immunosuppression or the physiologic demands of the malignancy itself. To our best knowledge, we firstly report on an immunocompetent patient subject to endoscopic submucosal dissection (ESD) for early esophageal cancer complicated with CMV infection. Case presentation A 77-year-old man underwent esophagogastroduodenoscopy (EGD) at a local clinic. EGD revealed a lugol-unstained reddish lesion with whitish exudates in the middle-distal esophagus. Histological evaluation of lesion biopsy revealed atypical squamous epithelium with CMV-positive granulation tissue and aggregates of macrophages, prompting referral for further examination and treatment. Magnifying endoscopy with narrow-band imaging showed an erosive lesion with white moss in a well-demarcated brownish area with irregular mesh-like microvessels. ESD was performed for diagnosis and treatment. Histopathological examination of the resected specimen revealed superficial, moderately differentiated squamous cell carcinoma (SCC) with multiple lymphatic infiltration, and few CMV-positive cells were found in the erosive part of the SCC. Interestingly, he had no underlying conditions to predispose to CMV infection and no risk factors for esophageal cancer, other than gender and age. He received neither steroids for stricture prevention nor antiviral agents post-EGD and 4-month follow-up was negative for esophagitis. Conclusions This is the first report of a case of CMV esophagitis superimposed on early esophageal cancer in an immunocompetent host and might provide valuable information for possible adverse effects of steroid administration during ESD procedures, despite their common use for prevention of post-ESD stricture.

Prognosis of Human Cytomegalovirus in Cancer Patients Undergoing Chemotherapeutic Treatment in Egypt and an Emergent Prevalence of Glycoprotein B-5

“…52 It was reported that HCMV reactivation was not only present in terminally advanced cancer patients, but with immune-competent ones as well making it necessary to suspect HCMV with pyrexia of unknown origin. 39,[53][54][55][56] HCMV reactivation could not be detected in any of the 93 cancer patients with mild to moderate level of immunosuppression after chemotherapy exposure, which is contrary to our results. 57 Schlick et al reported the case study of a patient with fever, pancreatic adenocarcinoma, and metastasis to the liver, lungs, and peritoneal cavity.…”

Global comparative transcriptomes uncover novel and population-specific gene expression in esophageal squamous cell carcinoma

“…Our analysis also revealed an overrepresentation of pathways related to virus infections among the DEGs, which was not surprising given the well-established links between certain microbial species such as HPV [ 91 ], CMV [ 55 , 56 ] (Table 4 ), and ESCC. In addition, we also observed an overrepresentation of KEGG pathways related to protozoans such as Amoebiasis and Leishmaniasis in our analysis, which is an interesting finding because both of these infections are prevalent disease throughout tropical and subtropical regions of the world.…”

“…Literature evidences support these plausible microbial infections in ESCC. For example (i) Infection of several species of Leishmania was observed with Squamous Cell Carcinoma in Brazil and Iran [52][53][54], and a long term infection of it suspected to induce DNA methylation alterations triggering tumorigenesis [52], (ii) CMV infection associated gastrointestinal tract lesion-esophagitis in a Japanese patient observed with a moderately differentiated squamous cell carcinoma [55] and reactivation of CMV infection among esophageal cancer patients undergoing chemotherapy in Japan [56], (iii) Cervical cancer patients in India [57] and colon cancer patients in India and Japan [58,59] found with Amoebiasis. Further, Entamoeba histolytica infects epithelial cells expressing EhADH adhesin together with the EhCP112 cysteine protease and damage epithelium [60].…”

Multi‐institutional questionnaire on treatment strategies for superficial entire circumferential esophageal squamous cell carcinoma

“… 18 However, as EC‐ESCC is not targeted in JCOG1217, the appropriate prophylactic treatment for EC‐ESCC remains unresolved. In addition, although this multi‐institutional questionnaire did not focus on the complications related to these treatments, many complications have been reported, 19 , 20 , 21 , 22 and it does not seem feasible to simply increase the dose and frequency of steroids in terms of efficacy and safety balance. Therefore, it is also important to identify the optimal prophylactic treatment after ESD for EC‐ESCC in a prospective multi‐institutional study.…”