J Med Cases
Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc
Journal website http://www.journalmc.org

Case Report

Volume 6, Number 10, October 2015, pages 480-482


Cytomegalic Infection in an Immunocompetent Patient: A Case With Multiple Organ Dysfunction

Joana Urbanoa, b, e, Sofia Moreira-Silvaa, b, Fernando Frioesb, c, Jorge Almeidab, c, Candida Abreub, d, Joana Pimentaa, b

aInternal Medicine Department, Centro Hospitalar Sao Joao, Porto, Portugal
bUniversity of Porto Medical School, Porto, Portugal
cIntermediate Care Unit of Medicine Department, Centro Hospitalar Sao Joao, Porto, Portugal
dInfectious Diseases Department, Centro Hospitalar Sao Joao, Porto, Portugal
eCorresponding Author: Joana Urbano, Internal Medicine Department, Centro Hospitalar Sao Joao, Alameda Professor Hernani Monteiro, 4200-319 Porto, Portugal

Manuscript accepted for publication August 13, 2015
Short title: Cytomegalic Infection on Immunocompetent
doi: http://dx.doi.org/10.14740/jmc2265w

Abstract▴Top 

Cytomegalic infection of the immunocompetent adult is usually asymptomatic or expressed by a mononucleosic syndrome. We present a case of a young adult with rare and severe primary cytomegalic infection and multisystemic involvement, namely hematological, hepatic, gastrointestinal and respiratory, including pneumonia with severe pulmonary hypertension, to the best of our knowledge, not previously described. Also of note is the fact that these dysfunctions were treated successfully with ganciclovir, although a formal indication to antivirals on cytomegalic infection of the immunocompetent patients is not established yet.

Keywords: Immunocompetent; Adult; Cytomegalovirus; Ganciclovir

Introduction▴Top 

Immunocompetent cytomegalic infection is characteristically asymptomatic or expressed by a mononucleosic syndrome [1]. Severe disease or multiple organ involvement is rare, so antiviral drugs are not routinely recommended [2, 3]. We report a case of a patient that illustrates two uncommon aspects of cytomegalic infection on immunocompetent individuals: severe multiple organ involvement, and the utility of antiviral drugs in that setting. Also of note is that the patient had diffuse pulmonary involvement causing acute cor pulmonale, as far as we know, just previously described associated with pulmonary embolism and not due to parenquimal attainment.

Case Report▴Top 

A 34-year-old man presented to the emergency department of our institution with a 1-week history of fever, myalgia, fatigue, loss of appetite, nausea, non-bloody diarrhea and intense right temporal headache. He had a history of light smoking habits (0.5 packs per year) and epilepsy, medicated with carbamazepine since childhood. On admission, his physical examination revealed fever, tachycardia, tachypnea, paleness and dehydration. On abdominal exam, he had both enlarged liver and spleen. Laboratory tests showed moderate lymphocytosis and normal C reactive protein. He was discharged with the diagnosis of acute non-bacterial enteritis and symptomatic medication was prescribed.

One week later, besides worsening diarrhea, he developed sore throat and serious retroocular headache, with intense photophobia. His wife reported an episode of delirium, with acute confusion and incoherent speech the night before. He was brought again to the emergency department, where he presented with a slightly ataxic gate with a left side deviation, fever, and swollen inflamed tonsils. The remainder neurological exam, as well as abdominal and chest examination were normal. Laboratory tests showed increased lymphocytosis with atypical lymphocytes on peripheral blood smear, as well as moderate normocytic anemia and thrombocytopenia of 115,000/mm3. C reactive protein was 61.3 mg/L (normal < 3 mg/L) and transaminases levels increased to almost two times the upper reference limit, with serum albumin of 32 g/L. Bilirubin and prothrombin time were within the normal range. Cerebral CT scan was normal, and no signs of infection were found in cerebrospinal fluid analysis. He was then admitted to internal medicine ward with suspected mononucleosic infection.

To exclude other etiologies of diarrhea, bacteriologic and parasitological fecal exams, fecal leucocytes testing and Widal reaction were performed, which were negative. He had a positive fecal occult blood test. Serological tests for Epstein-Barr virus, Coxiella burnetii, varicella zoster, herpes simplex virus (HSV), Toxoplasma gondii, and A, B and C hepatitis were negative. Cytomegalovirus (CMV) serology showed positive IgM and IgG titers, and blood polymerase chain reaction revealed 5.5 × 104 copies/mL of CMV DNA. Both primary and acquired immunodeficiencies were excluded by a negative human immunodeficiency virus test and normal concentration of immunoglobulin subtypes (IgG, IgA and IgM). Because of persisting neurological symptoms, with recurrent episodes of confusion and somnolence, lumbar puncture was repeated and a cerebral MRI was performed, both without alterations. No CMV, Listeria, enterovirus or HSV were detected in the cerebrospinal fluid. Electroencephalogram showed slow and irregular traces reflecting global cerebral dysfunction, without epileptic discharges. The patient developed worsening hematological dysfunction: minimum platelet count was 77,000/mm3 and hemoglobin dropped to 9.9 g/dL. Search for schizocytes was negative and lactic dehydrogenase level was within the normal range. Patient reported blurred vision and the ophthalmologic exam showed a little retinal hemorrhagic infiltrate and no signs of cytomegalic retinitis.

A few days later, symptoms of breathlessness and dry cough started and severe hypoxia was documented (ratio PaO2/FiO2 152). A thoracic CT scan identified enlarged mediastinal and hilar lymph nodes, as well as pulmonary micronodules, ground-glass parenchymal areas and small pleural and pericardial effusions, and showed no signs of pulmonary embolism. Transthoracic echocardiogram showed severe pulmonary hypertension (pulmonary artery systolic pressure of 70 mm Hg) and signs of acute cor pulmonale. At this time, patient was transferred to the intermediate care unit, where he began intravenous ganciclovir, at the dose of 5 mg/kg. Antiviral therapy was maintained for 21 days, with gradual improvement of the patient condition, progressive correction of respiratory failure, and neurological and hematological dysfunction.

The patient was discharged 26 days after admission, with complete resolution of respiratory insufficiency. He was re-evaluated periodically on the ambulatory clinic, repeating studies to exclude congenital or acquired immune deficiencies, including autoimmune diseases and malignancies. Pulmonary hypertension showed slow but complete resolution, as well as neurological deficits, hepatic and splenic enlargement, platelet count and hemoglobin. Resolution of constitutional symptoms was slower and occurred only after 18 months. IgG titers increased to a maximum of 1,207 AU/mL 11 months after the initial infection, with documented seroconversion after that.

Discussion▴Top 

This case documents an unusual presentation of CMV infection in an immunocompetent adult patient, with severe multisystemic involvement. We reviewed previous reports of severe CMV infection in immunocompetent adults, usually documenting single organ or system dysfunction [2-4]. Among these reports, the gastrointestinal [5-7] and respiratory tract [8], as well as central nervous system [3], were the most frequent sites of severe CMV infection. Other manifestations included hematological disorders (hemolytic anemia and thrombocytopenia) [9, 10], thrombosis of the venous or arterial vasculature [11] and ocular involvement [12]. In contrast to those reports, our patient presented with an unusual clinical scenario of important multisystemic involvement, namely hematological, neurological, enteric and respiratory. Besides he developed severe pulmonary hypertension, with acute cor pulmonale, to the best of our knowledge, not previously described due to parenquimal disease. Previous reports of pulmonary hypertension were associated with acute pulmonary embolism, which was not the case.

This case also stresses the efficacy of antiviral therapy in severe CMV infection in an immunocompetent patient, as the patient dysfunctions responded successfully to ganciclovir. There are some previous reports on the use of antiviral treatment for the most severe manifestations of cytomegalic infection, documenting good patient outcome [4, 7]. However, a formal indication to use ganciclovir in adult immunocompetent cytomegalic infection is still not established [2].

Grant Support

Not applicable.

Competing Interests

The authors declare that they do not have any competing interests.


References▴Top 
  1. Wreghitt TG, Teare EL, Sule O, Devi R, Rice P. Cytomegalovirus infection in immunocompetent patients. Clin Infect Dis. 2003;37(12):1603-1606.
    doi pubmed
  2. Lancini D, Faddy HM, Flower R, Hogan C. Cytomegalovirus disease in immunocompetent adults. Med J Aust. 2014;201(10):578-580.
    doi pubmed
  3. Rafailidis PI, Mourtzoukou EG, Varbobitis IC, Falagas ME. Severe cytomegalovirus infection in apparently immunocompetent patients: a systematic review. Virol J. 2008;5:47.
    doi pubmed
  4. Orasch C, Conen A. Severe primary cytomegalovirus infection in the immunocompetent adult patient: a case series. Scand J Infect Dis. 2012;44(12):987-991.
    doi pubmed
  5. Karakozis S, Gongora E, Caceres M, Brun E, Cook JW. Life-threatening cytomegalovirus colitis in the immunocompetent patient: report of a case and review of the literature. Dis Colon Rectum. 2001;44(11):1716-1720.
    doi pubmed
  6. Karigane D, Takaya S, Seki Y, Mastumoto Y, Onose A, Kosakai A, Sugaya N, et al. Cytomegalovirus enteritis in immunocompetent subjects: a case report and review of the literature. J Infect Chemother. 2014;20(5):325-329.
    doi pubmed
  7. Nazir S, Eledrisi M. Cytomegalovirus Infection in an Immunocompetent Host Presenting With Partial Bowel Obstruction. J Med Cases. 2015;6(4):153-155.
    doi
  8. Grilli E, Galati V, Bordi L, Taglietti F, Petrosillo N. Cytomegalovirus pneumonia in immunocompetent host: case report and literature review. J Clin Virol. 2012;55(4):356-359.
    doi pubmed
  9. Nomura K, Matsumoto Y, Kotoura Y, Shimizu D, Kamitsuji Y, Horiike S, Tamiwaki M. Thrombocytopenia due to cytomegalovirus infection in an immunocompetent adult. Hematology. 2005;10(5):405-406.
    doi pubmed
  10. Miyahara M, Shimamoto Y, Yamada H, Shibata K, Matsuzaki M, Ono K. Cytomegalovirus-associated myelodysplasia and thrombocytopenia in an immunocompetent adult. Ann Hematol. 1997;74(2):99-101.
    doi pubmed
  11. Ofotokun I, Carlson C, Gitlin SD, Elta G, Singleton TP, Markovitz DM. Acute cytomegalovirus infection complicated by vascular thrombosis: a case report. Clin Infect Dis. 2001;32(6):983-986.
    doi pubmed
  12. Radwan A, Metzinger JL, Hinkle DM, Foster CS. Cytomegalovirus retinitis in immunocompetent patients: case reports and literature review. Ocul Immunol Inflamm. 2013;21(4):324-328.
    doi pubmed


This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Journal of Medical Cases is published by Elmer Press Inc.

 

Browse  Journals  

     

Journal of clinical Medicine Research

Journal of Endocrinology and Metabolism

Journal of Clinical Gynecology and Obstetrics

World Journal of Oncology

Gastroenterology Research

Journal of Hematology

Journal of Medical Cases

Journal of Current Surgery

Clinical Infection and Immunity

Cardiology Research

World Journal of Nephrology and Urology

Cellular and Molecular Medicine Research

Journal of Neurology Research

International Journal of Clinical Pediatrics

 

 

 

 

 

Journal of Medical Cases, monthly, ISSN 1923-4155 (print), 1923-4163 (online), published by Elmer Press Inc.            
The content of this site is intended for health care professionals.
This is an open-access journal distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Creative Commons Attribution license (Attribution-NonCommercial 4.0 International CC-BY-NC 4.0)


This journal follows the International Committee of Medical Journal Editors (ICMJE) recommendations for manuscripts submitted to biomedical journals,
the Committee on Publication Ethics (COPE) guidelines, and the Principles of Transparency and Best Practice in Scholarly Publishing.

website: www.journalmc.org   editorial contact: editor@journalmc.org
Address: 9225 Leslie Street, Suite 201, Richmond Hill, Ontario, L4B 3H6, Canada

© Elmer Press Inc. All Rights Reserved.