Case Reports
Vol. 12 No. 1 (2020): Mediterranean Journal of Hematology and Infectious Diseases, Volume 12, 2020
Cytomegalovirus-Induced Gastrointestinal Bleeding and Pancreatitis Complicating Severe Covid-19 Pneumonia: a Paradigmatic Case.
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All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Received: June 1, 2020
Accepted: July 29, 2020
Accepted: July 29, 2020
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Key points:
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COVID-19 is a novel pandemic disease whose pathophysiology and clinical description are still not completely defined.
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Besides respiratory symptoms, gastrointestinal (GI) symptoms (especially including anorexia, diarrhea, and abdominal pain) represent the commonest clinical manifestations.
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Emerging data point out that severe SARS-CoV-2 infection causes an immune dysregulation, which in turn may favor other infections.
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Here we describe a patient with severe COVID-19 pneumonia who developed in the resolving phase abdominal pain associated to cytomegalovirus (CMV)-induced duodenitis with bleeding, and pancreatitis.
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A high level of suspicion toward multiple infections, including CMV, should be maintained in COVID-19 patients with heterogeneous clinical manifestations.
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Citations
1. Cheung KS, Hung IF, Chan PP, Lung K, Tso E, Liu R, Ng Y, Chu MY, Chung TW, Tam AR, Yip CC, Leung K-H, Yim-Fong Fung A, Zhang RR, Lin Y, Cheng HM, Zhang AJ, To KK, Chan K-H, Yuen K-Y, Leung WK (2020) Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples from the Hong Kong Cohort and Systematic Review and Meta-analysis. Gastroenterology, doi: https://doi.org/10.1053/j.gastro.2020.03.065.
2. Hamming I, Timens W, Bulthuis ML, Lely AT, Navis G, van Goor H (2004) Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis. J Pathol;203(2):631-637
3. Gu J, Han B, Wang J (2020) COVID-19: Gastrointestinal Manifestations and Potential Fecal–Oral Transmission. Gastroenterology. doi: 10.1053/j.gastro.2020.02.054
4. Tian Y, Rong L, Nian W, He Y (2020) Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther;51(9):843-851. doi: 10.1111/apt.15731. Epub 2020 Mar 31.
5. Liu F, Long X, Zou W, Fang M, Wu W, Li W, Zhang B, Zhang W, Chen X, Xhang Z (2020) Highly ACE2 Expression in Pancreas May Cause Pancreas Damage After SARS-CoV-2 Infection. Medrxiv. doi:https://doi.org/10.1101/2020.02.28.20029181
6. Beattie RM, Ashton JJ, Penman ID (2020) COVID-19 and the gastrointestinal tract: emerging clinical data. Frontline Gastroenterology. doi:10.1136/flgastro-2020-101507
7. Emery VC (2001) Investigation of CMV disease in immunocompromised patients. J Clin Pathol;54:84–88
8. Perdan-Pirkmajer K, Koren-Kranjc M, Tomsic M. A successfully treated pancreatitis caused by a CMV infection in a lupus patient. Lupus 2011;20(10):1104-5.
9. Terada T (2011) Cytomegalovirus-associated severe fatal necrotizing pancreatitis in a patient with interstitial pneumonitis treated with steroids. An autopsy case. JOP;12(2):158-61.
10. Kamalkumar BS, Agarwal SK, Garg P, Dinda A, Tiwari SC (2009) Acute pancreatitis with CMV papillitis and cholangiopathy in a renal transplant recipient. Clin Exp Nephrol;13(4):389-91
11. Sakakibara Y, Nakazuru S, Kodama Y, Mita E (2017) Acute pancreatitis caused by cytomegalovirus-associated duodenal papillitis. Annals of Gastroenterology. DOI: https://doi.org/10.20524/aog.2017.0188
12. Li H, Liu L, Zhang D, Xu J, Dai H, Tang N, Su X, Cao B (2020) SARS-CoV-2 and viral sepsis: observations and hypotheses. Lancet https://doi.org/10.1016/S0140-6736(20)30920-X
13. Giamarellos-Bourboulis EJ, Netea MG, Rovina N, Akinosoglou K, Antoniadou A, Antonakos N, et al. (2020) Complex Immune Dysregulation in COVID-19 Patients with Severe Respiratory Failure. Cell Host & Microbe https://doi.org/10.1016/j.chom.2020.04.009
14. Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB (2020) Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19) A Review. JAMA. doi:10.1001/jama.2020.6019
2. Hamming I, Timens W, Bulthuis ML, Lely AT, Navis G, van Goor H (2004) Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis. J Pathol;203(2):631-637
3. Gu J, Han B, Wang J (2020) COVID-19: Gastrointestinal Manifestations and Potential Fecal–Oral Transmission. Gastroenterology. doi: 10.1053/j.gastro.2020.02.054
4. Tian Y, Rong L, Nian W, He Y (2020) Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther;51(9):843-851. doi: 10.1111/apt.15731. Epub 2020 Mar 31.
5. Liu F, Long X, Zou W, Fang M, Wu W, Li W, Zhang B, Zhang W, Chen X, Xhang Z (2020) Highly ACE2 Expression in Pancreas May Cause Pancreas Damage After SARS-CoV-2 Infection. Medrxiv. doi:https://doi.org/10.1101/2020.02.28.20029181
6. Beattie RM, Ashton JJ, Penman ID (2020) COVID-19 and the gastrointestinal tract: emerging clinical data. Frontline Gastroenterology. doi:10.1136/flgastro-2020-101507
7. Emery VC (2001) Investigation of CMV disease in immunocompromised patients. J Clin Pathol;54:84–88
8. Perdan-Pirkmajer K, Koren-Kranjc M, Tomsic M. A successfully treated pancreatitis caused by a CMV infection in a lupus patient. Lupus 2011;20(10):1104-5.
9. Terada T (2011) Cytomegalovirus-associated severe fatal necrotizing pancreatitis in a patient with interstitial pneumonitis treated with steroids. An autopsy case. JOP;12(2):158-61.
10. Kamalkumar BS, Agarwal SK, Garg P, Dinda A, Tiwari SC (2009) Acute pancreatitis with CMV papillitis and cholangiopathy in a renal transplant recipient. Clin Exp Nephrol;13(4):389-91
11. Sakakibara Y, Nakazuru S, Kodama Y, Mita E (2017) Acute pancreatitis caused by cytomegalovirus-associated duodenal papillitis. Annals of Gastroenterology. DOI: https://doi.org/10.20524/aog.2017.0188
12. Li H, Liu L, Zhang D, Xu J, Dai H, Tang N, Su X, Cao B (2020) SARS-CoV-2 and viral sepsis: observations and hypotheses. Lancet https://doi.org/10.1016/S0140-6736(20)30920-X
13. Giamarellos-Bourboulis EJ, Netea MG, Rovina N, Akinosoglou K, Antoniadou A, Antonakos N, et al. (2020) Complex Immune Dysregulation in COVID-19 Patients with Severe Respiratory Failure. Cell Host & Microbe https://doi.org/10.1016/j.chom.2020.04.009
14. Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB (2020) Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19) A Review. JAMA. doi:10.1001/jama.2020.6019
Supporting Agencies
The study was supported by the Cariverona Foundation – ENACT projectHow to Cite
“Cytomegalovirus-Induced Gastrointestinal Bleeding and Pancreatitis Complicating Severe Covid-19 Pneumonia: a Paradigmatic Case. ” (2020) Mediterranean Journal of Hematology and Infectious Diseases, 12(1), p. e2020060. doi:10.4084/mjhid.2020.060.
