Budesonide
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Cytomegalovirus oesophagitis: case report An 85-year-old man developed cytomegalovirus (CMV) oesophagitis during treatment with budesonide for eosinophilic oesophagitis. The man presented with difficulty in ingesting and dysphagia since last one month. Twenty-five years prior to this presentation, he was diagnosed with lung squamous cell carcinoma, requiring right upper lobectomy with subsequent postoperative radiotherapy to the superior mediastinum. Six years prior, he also underwent oesophagogastroduodenoscopy (OGD) for the investigation of dysphagia, which revealed semicircular ulcers present at 22–24cm from the incisors. Upon investigation, he was diagnosed with eosinophilic oesophagitis and started receiving topical steroid therapy with oral viscous budesonide 1200µg daily. During the treatment, he had undergone balloon dilation therapy twice due to aggravation of dysphagia. However, cicatricial oesophageal stenosis persisted. No other history was reported. At the current presentation, an OGD scopy showed ulcerating mucosa, along with a thick white coat located 5–24cm from the incisors. The distal half of the ulcer showed luminal stenosis, which caused an oesophageal obstruction. However, the anal side mucosa of the stenosis stayed intact. The histopathological investigation of biopsy specimens of identified ulcers suggested CMV oesophagitis, which was suspected to be related to budesonide. No eosinophilic infiltration was noted. The contrast-enhanced CT-scan revealed wall thickening of the middle thoracic oesophagus. A barium contrast X-ray showed luminal stenosis. A CMV antigenemia assay and anti-HIV antibodies were not detected in his sera. The serology tests revealed positive results for IgG anti-CMV, while negative results for IgM anti-CMV. Based on laboratory findings, a diagnosis of CMV oesophagitis accompanied by eosinophilic oesophagitis was made. Hence, the man started receiving transvenous treatment with ganciclovir. For the alleviation of immunosuppressive effects of topical steroids, the dose of budesonide was decreased to 400µg. Three days after treatment with ganciclovir, he was able to ingest a liquid diet. Seven days after treatment with ganciclovir, an OGD revealed no ulcerative lesions, while immunostaining revealed no CMV antigens and intranuclear inclusions. He had received transvenous ganciclovir treatment for 12 days, along with oral valganciclovir treatment for additional 2 days. After 14 days of treatment, dysphagia resolved. Afterwards, his treatment with budesonide continued at 400µg daily. During the 1-year follow-up period, no recurrence of the CMV oesophagitis was noted. Suzaki K, et al. A case of cytomegalovirus esophagitis during topical steroid therapy for eosinophilic esophagitis. Clinical Journal of Gastroenterology : 1 Sep 2020. Available 803504730 from: URL: http://doi.org/10.1007/s12328-020-01219-z
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Reactions 3 Oct 2020 No. 1824
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