Postural Epigastric Pain: A Challenging Symptom for Cytomegalovirus (CMV) Gastritis

Abstract

Postural epigastric pain is an uncommon symptom and is hardly acquired unless specifically asked to the patient. Here we present a cytomegalovirus (CMV) gastritis case in a renal transplant patient with postural epigastric pain. A 36-year-old male was admitted to our clinic on the 50th day of renal transplantation with postural epigastric pain. All investigations were unremarkable except biopsy-proven CMV gastritis and increased CMV viral load. The patient was free of symptom after ganciclovir treatment. Postural epigastric pain has not been described together with a clinical entity. Although not proved yet, it can be regarded as a unique symptom of CMV gastritis. Renal transplant patients presenting with postural epigastric pain which is not relieved with acid suppression should raise suspicion of CMV gastritis and this has to be confirmed by endoscopy and biopsy.

• cytomegalovirus gastritis
• postural epigastric pain

INTRODUCTION

Cytomegalovirus (CMV) is the most common infectious complication in transplant recipients and gastrointestinal (GI) tract is the most commonly involved organ system.^1,2 CMV gastritis is of certain importance because of its reported association with postural epigastric pain.^3–5 Postural epigastric pain is an uncommon symptom and is hardly acquired unless specifically asked to the patient. It can be described as epigastric pain relieved in supine position, aggravated while sitting, and further increased with standing or walking. Reports about postural epigastric pain showed that it is almost always seen with CMV gastritis. Here we present a CMV gastritis case in a renal transplant patient with postural epigastric pain.

CASE REPORT

A 36-year-old male was admitted to nephrology service after renal transplantation from a cadaveric donor. He received basiliximab on the day of transplantation and post-operative 4th day. He was also started on cyclosporine, prednisolone, and mycophenolate mofetil in usual doses. On the 50th day of transplantation he was admitted with nausea, vomiting, fatigue, and loss of appetite. He also had sharp epigastric pain which was less when lying supine and increased with sitting, standing, and walking around. At that time he was on prednisolone 20 mg once a day, mycophenolate mofetil 1000 mg twice a day, and cyclosporine 150 mg twice a day. He had tenderness in the epigastric area without rebound or guarding. Laboratory data revealed mild neutrophilia, normal renal functions, slightly elevated liver enzymes, normal amylase, and lipase levels. Steroid-induced gastritis or gastric ulcer was considered as possible diagnosis. His epigastric pain was not relieved after gastric acid suppression with proton pump inhibitor therapy. Upper GI endoscopy showed antral gastritis and endoscopic biopsy was consistent with CMV gastritis. Viral serology showed extremely increased CMV viral load (360,000 copies/mL). Patient was started on intravenous ganciclovir treatment. His pain resolved in 2 days and he had full recovery after 3 weeks. Three weeks later CMV viral load was as low as 18 copies/mL.

DISCUSSION

CMV is the most common infectious complication in transplant recipients which is mostly seen in first 6 months and is associated with worse transplant outcomes.¹ GI tract is the most commonly affected organ system.² A recent study by Linares et al.¹ reported GI involvement including colitis, gastritis, and esophagitis in 38% of tissue-invasive CMV cases. Symptoms of CMV gastritis are nonspecific, including nausea, vomiting, fever, and bleeding. Endoscopic findings may vary, including diffuse erythema, erosions, nodules, and plaques.³

Postural epigastric pain is an uncommon symptom and is hardly acquired unless specifically asked to the patient. There are very few reports in the literature about diagnostic importance of this rare condition in patients with CMV gastritis. Giladi et al.⁴ reported three cases with CMV gastritis. All three cases had postural epigastric pain which was relieved by lying supine. All of them underwent endoscopic biopsy proving histological diagnosis of CMV infection. They were successfully treated with ganciclovir. Moustafellos et al.³ reported a patient with CMV gastritis. The patient was CMV negative before transplantation and did not receive prophylaxis for CMV. She was admitted with postural epigastric pain. She also had endoscopic biopsy to prove histological CMV gastritis and treated with ganciclovir.³ More recently Li et al.⁵ also reported a 34-year-old renal transplant recipient who presented with postural epigastric pain and was found to have biopsy-proven CMV gastritis.

In conclusion, postural epigastric pain is a rare symptom and it has not been described together with a clinical entity.^3–5 Although not proved yet, postural epigastric pain can be regarded as a unique symptom of CMV gastritis. Renal transplant patients presenting with postural epigastric pain which is not relieved with acid suppression should raise suspicion of CMV gastritis and this has to be confirmed by endoscopy and biopsy. Further studies should be performed on unique symptomatology of CMV gastritis, on prevalence of CMV gastritis in patients receiving different immunosuppressive drugs, and in patients on prophylaxis for CMV.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.