CMV encephalitis in an immune-competent patient

Clinic-radiological classification of herpesviral encephalitis in humans (systematic review)

The development of a comprehensive classification for herpesvirus encephalitis remains an urgent task. Distinct clinic-radiological forms of herpesvirus cerebral lesions have been characterized, including findings from histopathological studies. Differences among these forms have been demonstrated concerning key clinical and paraclinical parameters. The presented classification identifies several distinct forms of herpesvirus encephalitis: temporal, brainstem, limbic, diencephalic encephalitis, rhombencephalitis, leukoencephalitis, ventriculoencephalitis, diffuse glial micronodular encephalitis, subcortical and cortical encephalitis, cerebellitis, neonatal encephalitis. Additionally, the concepts of combined, coexisting and multimodal lesions are introduced to describe complex forms of herpesvirus neuroinfections. The use of the term "specific spectrum of herpesvirus cerebral lesions" is supported. Both the phenomena of specificity and universality are considered. Fundamental differences between the forms of herpesvirus encephalitis are highlighted with respect to their prevalence within the population, etiological factors, clinical manifestations, typical complications, recovery completeness, mortality rates, immune status. The distinctive diagnostic and therapeutic approaches required for each form of herpesvirus encephalitis are emphasized. The integration of this classification into clinical practice has the potential to optimize medical care for patients with herpesvirus encephalitis, enabling not only etiologically-oriented but also form-specific approaches to treatment.

The Wide Spectrum of Presentations of Cytomegalovirus Infection in Immunocompetent Hosts: An Exhaustive Narrative Review

CMV is a ubiquitous DNA virus that establishes infection and results in 40-100% seropositivity. Viral replication occurs following an acquired primary infection (or reinfection) or by the reactivation of life-long latency. In immunocompetent patients, CMV infection is mostly asymptomatic or mild and self-limited. However, an extensive review of the literature published up to April 2024 reveals that despite immunocompetence, CMV can cause a very large variety of clinical syndromes in any part of the gastrointestinal tract (the most common pattern), the central or peripheral nervous system, and the eyes, as well as hematological, pulmonary, cardiac, and cutaneous disease. Not uncommonly, more than one system is involved, and though the disease is often self-limited, treatment with intravenous ganciclovir or oral valganciclovir may be required, and in isolated cases, fatalities may occur. Thus, a potential CMV infection should be considered in the differential of myriad syndromes in non-immunocompromised patients. Associated systemic symptoms (fever, sweats, and weight loss), lymphocytosis, and hepatitis are not uncommon and can be a useful clue. Some populations, such as critically ill patients in intensive care, pregnant women, elderly patients, and those with inflammatory bowel disease, may be more susceptible. Moreover, the potential of past, latent CMV infection (i.e., CMV seropositivity) to be associated with significant cardiovascular morbidity and all-cause mortality years later is intriguing and requires further study. All these data indicate the outstanding importance of developing a vaccine against CMV, which hopefully will become available in the foreseeable future. Meanwhile, a solid diagnosis of active CMV infection can be quickly established (or ruled out) by widely available serology tests and PCR amplification, and clinicians in all disciplines need to be more aware of the diverse guises of CMV infection and remember to consider it in any host, including an immunocompetent one.

Risk Factors for Cytomegalovirus Retinitis in a National Survey in Sweden

PURPOSE

To investigate predisposing immunosuppressive conditions causing cytomegalovirus retinitis (CMVr) and risk factors for delayed diagnosis in patients diagnosed between 2008 and 2018 in the Swedish population of 10 million.

RESULTS

Sixty-three consecutive patients (100 eyes) were diagnosed with CMVr. The most common immunosuppressive state predisposing for CMVr was hematopoietic stem cell transplant recipients (27%) and hematological malignancy (24%). Two patients (3.2%) had no other predisposing factor than diabetes mellitus (DM). Patients with delayed diagnosis (≤30 days) were older than those with earlier diagnosis, mean age 68.7 (±9.8) and 48.8 (±17.6), respectively, p = .001. Signs of intraocular inflammation (IOI) were seen in 42 (70%) of cases and more common in delayed than early diagnosis, 16 (89%) and 21 (60%) respectively (p = .03).

CONCLUSION

Delayed diagnosis was more common in older individuals with signs of IOI. DM may be a risk factor for CMVr, and clinical signs can be mistaken for diabetic retinopathy.

[Reactivation of latent viruses in Neurology]

After establishing latent infection, some viruses can be reactivated by the alteration of host immunological conditions. First, we reviewed viruses that can cause neuronal damage by reactivation. Then we focused on the herpes simplex virus (HSV). The reactivation leads to neuronal damages through two possible mechanisms; "reactivation of a latent herpes virus" by which viruses can cause direct virus neurotoxicity, and "post-infectious immune inflammatory response" by which a focal reactivation of HSV leads to an inflammatory reaction. The former is radiologically characterized by cortical lesions, the latter is characterized by subcortical white matter lesions. We experienced a female, who underwent the right posterior quadrantectomy and then developed recurrent herpes encephalitis caused by herpes simplex reactivation, which pathologically demonstrated inflammation in the white matter, suggesting a post-infectious immune inflammatory response. The patient was successfully treated with immunosuppressants. The reactivation of the HSV is extremely rare in Japan. Neurologists should recognize this condition because this disorder will increase as epilepsy surgery gains more popularity.

Cytomegalovirus Meningoencephalitis in a Critically Ill Elderly Female: A Case Report

Cytomegalovirus (CMV) disease is usually a mild and self-limiting disease in immunocompetent patients. Recent evidence shows that CMV infection may also develop in the setting of critical illness, burn and sepsis and is usually associated with increased mortality rate and prolonged ICU stay. This paper describes an 83-year-old female who was initially admitted as a case of community-acquired pneumonia-high risk but remained febrile with paucity of verbal output despite correction of pneumonia and other electrolyte derangements. MRI showed the presence of peculiar-appearing signal abnormalities in the interhemispheric region and the anterior frontal convexities which were suspected to represent secondarily infected fluid collections. On lumbar tap, viral cerebrospinal fluid (CSF) panel showed a positive result for CMV infection. The patient was then given ganciclovir for 14 days followed by valganciclovir for three months. The most notable improvement was noted with the lysis of fever several days after starting anti-viral treatment. Verbal output remained limited, yet, on repeat tap after completion of treatment, CMV viral panel is now negative.

Cytomegalovirus meningoencephalitis in a case of severe COVID-19 Pneumonia. A case report

The use of steroids and other immune modulatory therapies in the treatment of severe COVID-19 pneumonia predisposes patients to the reemergence of opportunistic infections. Cytomegalovirus (CMV) reactivation can be one of them. A 55-year-old gentleman with severe COVID-19 pneumonia and hypoxic respiratory failure who was ventilated and received steroids but no other immunomodulatory drugs; had altered sensorium and multiple episodes of seizures in the later course of his illness. Brain MRI showed leptomeningeal enhancement and encephalopathy changes, electroencephalography (EEG) was suggestive of diffuse encephalopathy and his cerebrospinal fluid (CSF) analysis revealed high Cytomegalovirus PCR DNA titers (103,614). The patient made a complete recovery after treatment with Ganciclovir. Altered sensorium in cases of COVID-19 can be multifactorial. High index of suspicion for reactivation of dormant infections is warranted. CMV meningoencephalitis is one of the differential diagnoses. We believe this is the first case reported of CMV meningoencephalitis in the setting of severe COVID-19 infection.

Cytomegalovirus Seropositivity and Suicidal Behavior: A Mini-Review

Background and objectives: In recent years, a growing body of research has focused on identifying possible biological markers for suicidal behavior, including infective and immunological markers. In this paper, our aim was to review available evidence concerning the association between cytomegalovirus (CMV) infection and suicide. Materials and Methods: A systematic search according to the PRISMA statement was performed on Pubmed. After the screening procedure, we identified five relevant papers. Results: We found inconsistent evidence linking CMV infection and suicide, with some papers reporting an association between CMV seropositivity and suicidal behavior, and others not finding the association. Conclusions: With the evidence available presently, it is not possible to infer whether there is a correlation between suicide and CMV infection.