Co-Infection with Cytomegalovirus and Helicobacter pylori in a Child with Ménétrier's Disease
A 3-year-old boy visited the emergency department with an 11-day duration of anorexia, vomiting, and facial and peripheral edema. He had no previous history of medical problems, surgeries, medication use, or allergies. Family history was not notable. His body temperature was 36.6℃, heart rate was 72 beats/min, respiratory rate was 24/min, and blood pressure was 88/68 mmHg. Physical examination revealed swelling of the face, lower extremities, and scrotum. Breathing sounds were clear bilaterally without crackles or wheezing. His bowel sounds were normoactive and abdominal palpation showed no tenderness or hepatosplenomegaly. Initial complete blood cell count, electrolytes, blood urea nitrogen, creatinine, transaminases and cholesterol were unremarkable. But, serum protein and albumin were decreased (2.9 g/dL and 1.9 g/dL, respectively). The patient displayed no laboratory evidence of acute or chronic inflammation (erythrocyte sedimentation rate 2 mm/hr; C-reactive protein 0.08 mg/dL). No urinary protein was detected in urinalysis. At the second day of admission, esophagogastroduodenoscopy with gastric biopsy was performed, which revealed enlarged erythematous gastric folds in the entire stomach (). The diagnosis was protein-diminishing gastropathy with giant rugae (i.e., Ménétrier's disease). Along with the gastric biopsy and in-situ hybridization of specific viruses including CMV, Epstein-Barr virus and herpes simplex virus, we also performed an 13C urea breath test. The 13C urea breath test was positive(>2.0‰: cut-off value 2.0‰), prompting a 2-week regimen of lansoprazol, amoxicillin, and clarithromycin for Helicobacter pylori eradication. During the treatment, we noted the expected positive finding of recent CMV infection. Serologically, CMV immunoglobulin M was positive (IgM 1.19). A subsequent blood CMV polymerase chain reaction was positive and CMV antigenemia also was positive (18/200,000 white blood cells). Histologically, a gastric biopsy showed the proliferation of the gastric glands and cystic dilatation without increase of granulocytes or eosinophils, consistent with common histologic findings of Ménétrier's disease (). In addition, CMV intranuclear inclusions were detected from gastric tissue using in-situ hybridization (). H. pylori was not detected in Giemsa-stained sections. Although not totally normalized, the patient's appetite, peripheral edema, and hypoalbuminemia improved sufficiently to allow discharge after 8 days of supportive care such as fluid restriction, albumin infusion, diurectics, high-protein diet. Seven weeks after discharge, follow-up esophagogastroduodenoscopy with biopsy and 13C urea breath test were done. The patient did not complain of any notable symptoms and endoscopy was nearly normalized, both grossly and microscopically (). But the 13C urea breath test was still positive despite 2 weeks of H. pylori eradication treatment.