Cytomegalovirus-associated esophageal ulcer in an immunocompetent infant: When should ganciclovir be administered?
A previously healthy 7-week-old female infant presented with aggravated vomiting (4 to 5 times daily) and feeding intolerance of 10 days duration. Her perinatal course was uneventful, and she thrived with formula feeding. A physical examination revealed generalized lethargy with mild dryness of oral mucosa. Her body weight was in the 25 percentile (birth weight was in the 50 percentile). The abdomen revealed no hepatosplenomegaly. Laboratory data showed a white blood cell count of 12,740/mm3 with a normal differential cell count, hemoglobin of 9.3 g/dL, and a platelet count of 311,000/mm3. The serum electrolytes, creatinine and blood urea nitrogen, aspartate aminotransferase, and alanine aminotransferase were normal. Cultures of blood, urine, and stool were negative. A stool examination showed negativity for occult blood, and the rotavirus stool test was negative. C-reactive protein was 2.26 mg/dL. Ultrasonography showed no evidence of abnormally thickened pyloric muscle or of an elongated pyloric canal. A barium meal study showed gastroesophageal reflux (GER) grade II and an ulcer-like lesion in the distal esophagus (). Esophagogastroduodenoscopy (EGD) revealed a huge ulcer with multiple erosions (). A cow's milk elimination test with protein hydrolysate was performed, but no clinical response was observed. Eosinophilic esophagitis was excluded by microscopic findings. The frequency of vomiting improved to 2 to 3 times per day after starting PPI. Serology for human immunodeficiency virus, Toxoplasma, herpesvirus, and Epstein-Barr virus infections were all negative. However, enzyme-linked immunosorbent assay titers were positive for CMV immunoglobulin M and urine polymerase chain reaction also indicated positivity for CMV. A second EGD performed 2 weeks after the initiation of PPI showed that the erosions had disappeared and the esophageal ulcer was improved in terms of size and depth. First and second endoscopic biopsy specimens from the esophageal ulcer were reviewed and inclusion bodies and immunohistochemical staining for CMV were positive in the 1st specimens but negative in the 2nd specimens. Both lymphocyte subset and immunoglobulins were within normal limits, and brain magnetic resonance imaging, an auditory evoked potential test, and ophthalmological examination showed normal findings. PPI was prescribed for a total of 1 month, but ganciclovir was not administered. After discharge, the patient showed good weight gain and no symptoms of vomiting or feeding intolerance. A follow-up barium meal study performed at 8 months of age showed normal findings and no evidence of an esophageal ulcer, stricture, or GER.