Protein-losing gastropathy associated with CMV infection in children. Menetrier’s disease? A case report

Background: Menetrier's disease is a rare form of acquired gastropathy characterized by giant rugal folds in the stomach lining and protein-losing gastropathy; in children, it rarely needs aggressive treatment and resolves spontaneously within 2–10 weeks with support therapy. Many cases of pediatric Menetrier's disease associated with cytomegalovirus (CMV) infection have been reported. Clinical findings include nausea, vomiting, abdominal pain, peripheral edema, ascites, and pleural effusion. Gastroduodenal endoscopy is useful in confirming the diagnosis and excluding other similar conditions as lymphoma, eosinophilic gastropathy, gastric varices, Zollinger-Ellison syndrome and lymphangectasia. Specific aim: We describe a case of protein-losing gastropathy, associated with primary CMV infection. Case report: An 18-month-old male presented with periorbital swelling, vomiting and food refusal. Blood tests on admission showed hypoalbuminemia, IgG hypogammaglobulinemia, hypocalcemia and a high peripheral blood eosinophil count. Metabolic, allergologic and autoimmune diseases were ruled out. His immunological profile was normal. Tests for infectious diseases revealed a primary CMV infection. The Guthrie card test for CMV PCR was negative. Endoscopy revealed a normal macroscopic picture of the digestive sections examined and histological examination of multiple oesophageal, gastric and duodenal biopsies was normal. In contrast, the ultrastructural examination of the biopsies revealed signs of viral infection. Considering the diagnostic hypothesis of protein-losing gastropathy associated with CMV infection, a proton pump inhibitor with support therapy and a dose of IgG immunoglobulins to treat the IgG hypogammaglobulinemia were administered. The child was discharged in good clinical condition, with monthly outpatient follow-up for 6 consecutive months. Conclusions: Although CMV infection appears to be the major cause of Menetrier's disease in infants, in our case, the lack of endoscopic and histological features suggestive of Menetrier's disease led us to consider a form of protein-losing gastropathy associated with CMV infection. It is important for pediatric emergency departments to consider the often misdiagnosed Menetrier's disease, together with the other causes of protein-losing enteropathy, in the differential diagnosis for edema and low albumin levels.