NIH Public Access Author Manuscript Minn Med. Author manuscript; available in PMC 2015 September 01.
NIH-PA Author Manuscript
Published in final edited form as: Minn Med. 2014 September ; 97(9): 50.
CMV esophagitis as a cause of failure to thrive Benjamin R. Hanisch1 and Kiran Belani1,2 1University
of Minnesota Medical School, Minneapolis
2Children's
Hospital & Clinics of Minnesota Cytomegalovirus (CMV) is one of the most common congenital viral infections in the developed world (1). While many children are asymptomatic, CMV is associated with a wide range of complications including sensorineural hearing loss, microcephaly, developmental delay (1,2) and rarely esophagitis (3). This case illustrates CMV esophagitis presenting as failure to thrive in an infant.
NIH-PA Author Manuscript
A 7 week old male presented to the emergency department for failure to thrive and persistent vomiting. Four weeks prior he had developed projectile vomiting and underwent an evaluation including an abdominal ultrasound, upper GI, blood cultures and blood work remarkable for a mild increase in transaminases. He was diagnosed with reflux and discharged on lanzoprazole. The family subsequently returned concerned that he was 4 ounces below his birth weight at 7 weeks of age. They report he would vomit immediately after eating though was eager to feed shortly after vomiting. He was initially breast fed and has tried soy and elemental formulas without improvement. His medical history was remarkable for repeat caesarean section (mother's 3rd child) at 39 weeks and a birth weight of 3 kg (10th percentile). The remainder of a complete review of systems was negative. Physical examination revealed a thin well appealing child with a heart rate of 150 bpm, respiratory rate of 24 bpm, with no oral ulcerations, a strong suck, no murmurs, soft abdomen without organomegaly, normal tone and no rashes or edema.
NIH-PA Author Manuscript
His laboratory evaluation was remarkable for an elevated AST 143 and an ALT 201, WBC of 15.5 ×109 cells/L with 85% lymphocytes, platelets 256 ×109 cells/Land a normal X-ray of the chest and abdomen. His esophagogastroduodenoscopy (EGD) was remarkable for patchy esophageal ulcerations and mild gastritis and biopsies were positive for CMV on immunohistochemical staining (figure 1). CMV serology was positive for IGM and IGG, and CMV PCR of the blood was detectable though not quantifiable. There were no signs of intracranial calcifications or hearing loss on subsequent evaluation. The patient was treated with IV ganciclovir 12 mg/kg divided twice daily and he was soon able to feed by mouth and gain weight. He was then transitioned to oral valganciclovir 32 mg/kg divided twice daily to complete a four week course.
Hanisch and Belani
Page 2
Conclusion NIH-PA Author Manuscript
CMV is a common congenital viral infection and its presentations can be quite variable. This case illustrates that CMV esophagitis should be considered in infants with persistent vomiting, particularly if there are other supportive findings such suggestive of CMV such as increased transaminases, small for gestational age, thrombocytopenia, or hearing loss.
References 1. Dollard, Sheila. New estimates of the prevalence of neurological and sensory sequelae and mortality associated with congenital cytomegalovirus infection. Reviews in medical virology. 2007; 17(5): 355–363. [PubMed: 17542052] 2. Swanson, Elizabeth C.; Schleiss, Mark R. Congenital cytomegalovirus infection: new prospects for prevention and therapy. The Pediatric clinics of North America. 2013; 60(2):335–349. 3. Azimi P, Petru A. Severe esophagitis in a newborn infant. The Pediatric infectious disease journal. 1996; 15(4):385–385. [PubMed: 8866817]
NIH-PA Author Manuscript NIH-PA Author Manuscript Minn Med. Author manuscript; available in PMC 2015 September 01.
Hanisch and Belani
Page 3
NIH-PA Author Manuscript NIH-PA Author Manuscript
Figure 1. CMV immunohistochemical stain, 400×, positive nuclear staining
NIH-PA Author Manuscript Minn Med. Author manuscript; available in PMC 2015 September 01.
NIH-PA Author Manuscript
Published in final edited form as: Minn Med. 2014 September ; 97(9): 50.
CMV esophagitis as a cause of failure to thrive Benjamin R. Hanisch1 and Kiran Belani1,2 1University
of Minnesota Medical School, Minneapolis
2Children's
Hospital & Clinics of Minnesota Cytomegalovirus (CMV) is one of the most common congenital viral infections in the developed world (1). While many children are asymptomatic, CMV is associated with a wide range of complications including sensorineural hearing loss, microcephaly, developmental delay (1,2) and rarely esophagitis (3). This case illustrates CMV esophagitis presenting as failure to thrive in an infant.
NIH-PA Author Manuscript
A 7 week old male presented to the emergency department for failure to thrive and persistent vomiting. Four weeks prior he had developed projectile vomiting and underwent an evaluation including an abdominal ultrasound, upper GI, blood cultures and blood work remarkable for a mild increase in transaminases. He was diagnosed with reflux and discharged on lanzoprazole. The family subsequently returned concerned that he was 4 ounces below his birth weight at 7 weeks of age. They report he would vomit immediately after eating though was eager to feed shortly after vomiting. He was initially breast fed and has tried soy and elemental formulas without improvement. His medical history was remarkable for repeat caesarean section (mother's 3rd child) at 39 weeks and a birth weight of 3 kg (10th percentile). The remainder of a complete review of systems was negative. Physical examination revealed a thin well appealing child with a heart rate of 150 bpm, respiratory rate of 24 bpm, with no oral ulcerations, a strong suck, no murmurs, soft abdomen without organomegaly, normal tone and no rashes or edema.
NIH-PA Author Manuscript
His laboratory evaluation was remarkable for an elevated AST 143 and an ALT 201, WBC of 15.5 ×109 cells/L with 85% lymphocytes, platelets 256 ×109 cells/Land a normal X-ray of the chest and abdomen. His esophagogastroduodenoscopy (EGD) was remarkable for patchy esophageal ulcerations and mild gastritis and biopsies were positive for CMV on immunohistochemical staining (figure 1). CMV serology was positive for IGM and IGG, and CMV PCR of the blood was detectable though not quantifiable. There were no signs of intracranial calcifications or hearing loss on subsequent evaluation. The patient was treated with IV ganciclovir 12 mg/kg divided twice daily and he was soon able to feed by mouth and gain weight. He was then transitioned to oral valganciclovir 32 mg/kg divided twice daily to complete a four week course.
Hanisch and Belani
Page 2
Conclusion NIH-PA Author Manuscript
CMV is a common congenital viral infection and its presentations can be quite variable. This case illustrates that CMV esophagitis should be considered in infants with persistent vomiting, particularly if there are other supportive findings such suggestive of CMV such as increased transaminases, small for gestational age, thrombocytopenia, or hearing loss.
References 1. Dollard, Sheila. New estimates of the prevalence of neurological and sensory sequelae and mortality associated with congenital cytomegalovirus infection. Reviews in medical virology. 2007; 17(5): 355–363. [PubMed: 17542052] 2. Swanson, Elizabeth C.; Schleiss, Mark R. Congenital cytomegalovirus infection: new prospects for prevention and therapy. The Pediatric clinics of North America. 2013; 60(2):335–349. 3. Azimi P, Petru A. Severe esophagitis in a newborn infant. The Pediatric infectious disease journal. 1996; 15(4):385–385. [PubMed: 8866817]
NIH-PA Author Manuscript NIH-PA Author Manuscript Minn Med. Author manuscript; available in PMC 2015 September 01.
Hanisch and Belani
Page 3
NIH-PA Author Manuscript NIH-PA Author Manuscript
Figure 1. CMV immunohistochemical stain, 400×, positive nuclear staining
NIH-PA Author Manuscript Minn Med. Author manuscript; available in PMC 2015 September 01.
