부. 울. 경 소화기내시경집담회 2014.05.07 고신대학교복음병원소화기내과전임의한유진
CASE 55/M C/C Hematemesis for 1day
P/I #2014.3.11 whole body rash with itching sense #3.25 Bullous pemphigoid dermatology #3.26 po steroid start #4.4 po azathioprine start #4.7 discharged with skin lesion improvement epigastric pain onset after leaving hospital #4.8 about 4:00 am, hematemesis onset admitted via ER
Past Hx DM/HTN/Pul. Tb./Hepatitis denied by Pt. OP Hx.(-), allergy(-), Drug Hx (-) Mental retardation Social Hx Occupation: none Alcohol/smoking(-/-) Family Hx: N-S
Review of system General weakness/ Fatigue/ Wt.loss (-/-/-) Fever/ Chill/ Myalgia (-/-/-) Headache/ Dizziness/ Visual disturbance (-/+/-) Cough/ Sputum/ Rhinorrhea/ Dyspnea/Chest pain (-/-/-/-/-) DOE / Palpitation (-/-) Anorexia/ Nausea/ Vomiting/ Constipation/ Diarrhea (-/+/+/-/-) Abdominal pain/ Abdominal discomfort/ Epigastric soreness/ Indigestion (-/-/+/-) Hematemesis/ Melena/ Intermittent blood tinged stool (+/-/-) Oliguria/ Polyuria/ Dysuria/ Hematuria (-/-/-/-)
Physical exam General app.- Relatively ill being app. HEENT- Not dehydrated tongue Anemic conjunctivae Anicteric sclera Palpable L/N (-/-) Chest - Sym s deformity - RHB s murmur - CBS s rale Abdomen- soft & flat - Tenderness/rebound tenderness(-/-) - Hyperactive bowel sound - No palpable mass - DRE (+, melena) Back/ Ext.- CVAT(-/-) - Pretibial pitting edema(-)
Lab finding CBC 37,040-9.1-510K Na/K 128/4.3 BUN/ Cr 19.1/0.34 Protein/Alb 5.5/2.9 AST/ALT 32/53 TB/DB 0.97/0.42 CEA/CA19-9 1.62/0.6 ESR/HR-CRP 3/0.11 Stool OB (+)
CMV IgG Pos (25) CMV IgM Neg (0.05) CLO test Neg
Diagnosis CMV infection, involving Upper GI tract
Progress Ganciclovir 5mg/kg q 12hr IV for 2 weeks
TEXT REVIEW CMV infection in GI Tract
특징 Double stranded DNA, Herpes virus 군 면역저하자 > 면역정상 Steroid, Immunosupressants, Cancer, Trasplantation, AIDS 잠복바이러스재활성 > 초감염, 재감염 Lymphocyte, monocyte, PMN
특징 The most common disease manifestation GI disease 경계가분명한궤양 다발성미란 점막부종 점막결절 most common at Colon
증상 복통, 설사, 체중감소 장출혈 장천공 - 회장말단부, 근위부대장
진단 Biopsy of the tissue Direct fluorescent antibody tests DNA hybridization Rapid cultures Cytology CMV IgA antibody CMV DNA PCR and pp65 antigen?? GI tract ds 25%- negative No consensus on CMV DNA Level High on negative predictive value
치료 Ganciclovir 5mg/kg q 12hr IV Valganciclovir 900mg bid po Foscarnet 200mg/kg/day 치료기간 : Induction : 2 weeks ( If, tolerable : 3 weeks ) Maintenance: 3-4 weeks 평균 3-6 weeks 임상및내시경소견에따라 case by case PPI or H2RA without antiviral agent?
28/M Immunocompetent WBC 7690/mm3 Normal : CD3,CD4,CD8,CD4/CD8 ratio H.pylori (-) Drug Hx (-)
PPI for 2weeks f/u improve Immunocompetent PPI for 2 month
면역정상, 임상양상, 만성질환유무, 약물치료반응고려하여항바이러스제의치료에앞서항궤양제의보전적치료를시도 CMV- 병변의일차적원인 or - 이미있던궤양성병변에이차적으로감염된비병원성의 bystander?
Recommend antiviral agent to Over age 55 DM, Renal failure Pregnancy
References 소화기계질환제 3 판 - 김정룡외저 Complication, Diagnosis, Management, and Prevention of CMV Infections: Current and future Michael Boeckh, Fred Hutchinson Cancer Reserch Center, Seattle,WA, American society of hematology 2011;305-309 CMV Gastric Ulcers healed by supportive Therapy, Hyoung Don Lee,M.D.ect, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea, The Korean Journal of Gastrointestinal Endoscopy, 2011;43:21-24 Cytomegalovirus colitis in immunocompetent patients. Momin N, Telisinghe PU, Chong VH.Singapore Med J. 2011 Sep;52(9):e170-2 CMV quantiatative PCR in the diagnosis of CMV-associated AGML in an immunocompetnt host.matsui Y, Sugino N, Kaneko H, Watanabe M, Miura Y, Tsudo M.Intern Med. 2010;49(12):1265-7