PMC7372912_01
Chest and abdominal radiographs at the ileal perforations. (A) First perforation at day of life 8. Arrows indicate free air in the intraperitoneal space. (B) Second perforation at day of life 17. Arrowheads indicate free air in the intraperitoneal space.
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F1
At DOL8, bilious residuals were collected from the nasogastric tube and abdominal radiography showed pneumoperitoneum (Figure 1A). Abdominal distension appeared again at DOL17 and abdominal radiography showed recurrence of pneumoperitoneum (Figure 1B).
The association of clinical manifestation and treatments with the laboratory findings. Histological analyses of the affected intestines were performed before and after the 6-week treatment with ganciclovir. Cytomegalovirus DNA was measured in the dry preserved umbilical cord obtained within a week from birth, the urine and the blood at the designated time points by the real-time polymerase chain reaction assay. DOL, day of life; PDA, patent ductus arteriosus; RBC, red blood cell; CMV, cytomegalovirus; NA, not available; AST, aspartate aminotransferase; ALT, alanine aminotransferase.
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F2
After the operation, dyspepsia persisted and hepatic transaminases were elevated from DOL14 (Figure 2). After starting GCV therapy at DOL34, dyspepsia and abdominal distension resolved and CMV-DNA in the blood was concurrently decreased to lower than detection level by DOL70 (Blood CMV-DNA: 1.3 x 107 [copies/mL] at DOL 28; 3.6 x 106 at DOL 35; 6.2 x 104 at DOL 56; 2.9 x 104 at DOL 63; less than detection level at DOL 70 and 77, Figure 2).
Histological analysis of the intestinal resection specimens. (a) Resected ileum at the 1st perforation at day of life (DOL) 8. The vasodilatation and bleeding are observed. (Hematoxylin-eosin stain, original magnification x 400). (b) Resected ileum at the 2nd perforation at DOL17. An arrowhead indicates the inclusion body. (Hematoxylin-eosin stain, original magnification x 400). (c) Resected ileum at the final ileostomy closure at DOL94. Inclusion body is not identified. (Hematoxylin-eosin stain, original magnification x 400). (d) Resected ileum at the 1st perforation at DOL8 immunostained with anti-cytomegalovirus (CMV) antibody. (clone DDG9/CCH2, Dako) Arrows indicate the CMV immunostaining-positive endothelial cells. (original magnification x 400). (e) Resected ileum at the final ileostomy closure immunostained with anti-CMV antibody. No CMV positive cells are observed. Each scale bar indicates 50 mum.
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F3
Pathological examination of the resected ileum revealed non-specific inflammatory changes which were consistent with enterocolitis and CMV inclusion bodies were not identified (Figure 3a). Pathological examination of the second operation, which was reported at DOL30, showed characteristic CMV intranuclear inclusion bodies in the endothelium of lamia propria (Figure 3b). CMV with the intestinal specimen at the first surgery on DOL8, which was performed retrospectively after the result of pathological examination of the second operation was reported, demonstrated small amount of CMV positive cells (Figure 3d). CMV-DNA was also detected in both blood and urine at DOL28. CMV inclusion body or CMV immunoreactivity were not detected in the resection specimen at the final ileostomy closure (Figures 3c,e).