Acquired cytomegalovirus infection

Fever of unknown origin (FUO): CMV infectious mononucleosis or lymphoma?

Fever of unknown origin (FUO) refers to fevers of > 101 °F that persist for > 3 weeks and remain undiagnosed after a focused inpatient or outpatient workup. FUO may be due to infectious, malignant/neoplastic, rheumatic/inflammatory, or miscellaneous disorders. The FUO category determines the focus of the diagnostic workup. In the case presented of an FUO in a young woman, there were clinical findings of both CMV infectious mononucleosis or a lymphoma, e.g., highly elevated ESR, elevated ferritin levels, and elevated ACE level, β-2 microglobulins. The indium scan showed intense splenic uptake. Lymph node biopsy, PET scan, and flow cytometry were negative for lymphoma. CMV infectious mononucleosis was the diagnosis, and she made a slow recovery.

Sarcoidosis with fever and a splenic infarct due to CMV or lymphoma?

We present a case of an adult female with a past history of pulmonary sarcoidosis who presented with fever, night sweats, profound fatigue, and LUQ abdominal pain. Sarcoidosis is an afebrile disorder (excluding Lofgren's syndrome, Heerfordt's syndrome or neurosarcoidosis). Therefore, the presence of fever with sarcoidosis should suggest infection, usually viral, or lymphoma. Sarcoidosis-lymphoma syndrome describes the evolution of a lymphoma in long standing sarcoidosis. Fever aside, possible lymphoma is suggested by otherwise unexplained fever, pleural unilateral effusion, highly elevated ESR or ferritin levels. In this case, a viral etiology was suggested because of atypical lymphocytosis and mildly elevated transaminases. In this patient, CMV IgM titers and elevated CMV PCR viral load confirmed the diagnosis of CMV infectious mononucleosis with lung and liver involvement. In this case CMV infectious mononucleosis was accompanied by procoagulant activity which resulted a DVT, pulmonary emboli and splenic infarct. We believe this to be the first reported case of CMV infectious mononucleosis splenic infarct in a patient with a history of sarcoidosis.

Cytomegalovirus infection in immunocompetent wheezy infants: the diagnostic value of CMV PCR in bronchoalveolar lavage fluid

WHAT IS KNOWN AND OBJECTIVE

Cytomegalovirus (CMV) pneumonitis in immunocompetent hosts is uncommon but is being recognized more frequently, particularly when presenting as severe viral pneumonia. The objective of this study was to examine lower respiratory tract CMV infection in immunocompetent wheezy infants, based on polymerase chain reaction (PCR) in bronchoalveolar lavage (BAL) fluid, to compare CMV PCR results in BAL and in blood samples and to evaluate the benefits of antiviral ganciclovir therapy in these patients.

METHODS

Retrospective review of the records of patients referred to our tertiary care hospital between January 2000 and July 2010 who had unexplained persistent wheezing and underwent fibreoptic flexible bronchoscopy (FFB).

RESULTS AND DISCUSSION

Fibreoptic flexible bronchoscopy was applied to 102 infants with persistent wheezing and diffuse interstitial infiltration on radiological investigations; so CMV PCR in BAL fluid was performed. CMV PCR in BAL fluid was positive in 51 patients. Retrospectively, we had access to the files of 25 of these patients. The mean CMV PCR in BAL fluid was 334 840 copies/mL. Only eight patients had CMV PCR positivity in their blood samples (mean: 2026·3 copies/mL). There was not a relationship between BAL and blood CMV PCR values based on Spearman's correlation analysis (r = -0·008). Fourteen patients had severe respiratory symptoms and received ganciclovir therapy. Twelve of them fully recovered.

WHAT IS NEW AND CONCLUSION

Bronchoalveolar lavage fluid CMV PCR was superior to blood CMV PCR in diagnosing lower respiratory tract infections caused by CMV in immunocompetent infants. Ganciclovir therapy may be effective in selected immunocompetent wheezy infants with CMV PCR positivity in BAL fluid.

Cytomegalovirus pneumonia in immunocompetent host: case report and literature review

CMV infection is highly prevalent in general population and its clinical picture generally ranges from asymptomatic disease to mononucleosis-like syndrome. While severe life-threatening CMV disease is well documented in certain immunocompromised risk groups, severe infection with symptomatic pneumonia in immunocompetent hosts has been rarely documented. In this paper we describe a case of primary CMV infection, complicated by severe CMV pneumonia in an immunocompetent host, successfully treated with oral valganciclovir. Moreover, we reviewed CMV pneumonia cases in immunocompetent adults reported in the literature.

H1N1-associated acute retinitis

PURPOSE

To present the first reported case of bilateral H(1)N(1)-associated acute retinitis and its successful treatment.

DESIGN

Interventional case report.

METHODS

A 41-year-old HIV-positive male presented with acute vision loss, panuveitis, and retinitis. A diagnostic and therapeutic vitrectomy with intravitreal injection of vancomycin and ganciclovir and endolaser was performed. One month later, the patient returned with similar symptoms in the fellow eye and underwent the same procedure.

RESULTS

ELISA immunoassay revealed H(1)N(1) antibodies in both the vitreous and serum. PCR for herpes viruses included HSV, CMV, and VZV. Bacterial and fungal cultures were negative. On 1-year follow-up, the vision remained 20/20 in both eyes without evidence of recurrent inflammation.

CONCLUSIONS

H(1)N(1) should be included in the differential diagnosis of any patient with a history of recent influenza A (H(1)N(1)) infection and acute retinitis. H(1)N(1) may carry a better prognosis than other viruses causing acute retinitis.

Systemic viral infections and their retinal and choroidal manifestations

Viruses are one of the most common causes of infections involving the posterior segment of the eye. Such infections can occur either on a congenital or an acquired basis, and may affect primarily the retina or the choroid. Congenital cytomegalovirus (CMV) and rubella infections may result in retinitis. CMV retinitis is also the most common cause of acquired viral retinitis, primarily because of the acquired immunodeficiency syndrome (AIDS). Other types of viral retinitis, such as those caused by herpes simplex or herpes zoster, can occur in immunocompromised or immunocompetent individuals. Retinitis or choroiditis caused by viruses such as measles, influenza, Epstein-Barr virus, and Rift Valley fever virus, typically occurs subsequent to an acute viral systemic illness. The systemic and ocular manifestations, as well as the histopathology, laboratory tests, differential diagnoses, and treatment regimens for each of the individual viruses are discussed in detail.

Cytomegalovirus mononucleosis in children compared with the infection in adults and with Epstein-Barr virus mononucleosis

We report clinical and laboratory findings in 11 previously healthy children with cytomegalovirus (CMV) mononucleosis and compare them with those of 18 adults with CMV mononucleosis and with those of 22 age-matched children with Epstein-Barr virus (EBV) mononucleosis. Exudative pharyngitis was more common in children whereas prolonged fever was more common in adults. Prominent lymphadenopathy and exudative pharyngitis, however, were less frequent in children with CMV mononucleosis than in those with EBV mononucleosis. Nevertheless, children with CMV mononucleosis are more likely to resemble those with EBV mononucleosis than adults with CMV mononucleosis.

Transfusion-associated viral infections

Viral infections are a frequent occurrence following transfusion of blood products. While generally benign, these infections are capable of causing significant morbidity and mortality. Therefore, it is prudent to follow several general approaches diligently to reduce the risks of these infections in patients undergoing transfusions of blood products. These suggested measures include the following: 1. Prescribe and administer blood and blood products only when absolutely needed. 2. Use volunteer blood donors only. 3. Avoid use of pooled blood products when possible. 4. Use only blood and blood products that have been appropriately tested for HBsAg and HIV. 5. Use ALT determinations to screen blood products and eliminate those with high level. 6. Avoid the use of clotting-factor concentrates but, if necessary, use only those which have been heat-treated. 7. Limit use of leukocyte transfusion. 8. Use only CMV seronegative blood and blood products or frozen deglycerolized red cells in patients at high risk for posttransfusion CMV infection.

Cytomegalovirus mononucleosis in children and adults: differences in clinical presentation

In 2 previously healthy groups of 14 children and 17 adults with cytomegalovirus mononucleosis, significant clinical differences were observed. Cervical lymphadenopathy, hepatomegaly and lymphocytosis (greater than 5000/microliter) were more common in children and protracted fever more common in adults. Exudative tonsillitis indistinguishable from infectious mononucleosis was sometimes seen in children but never in adults.

Cytomegalovirus infection with perfusion defects on the lung scan

A patient with dyspnea, skin rash, hypoxemia and mononucleosis was shown to have acute cytomegalovirus infection. The chest X-ray was normal, but the lung scan showed perfusion defects. Although pulmonary embolism cannot be ruled out, it seems likely that the CMV infection was responsible for the abnormalities observed.

Cytomegalovirus myocarditis

A male patient, aged 31 years, with a cytomegalovirus (CMV) myocarditis is described, who showed a high IgM antibody titer for cytomegalovirus infection of 1:1,024 and a rise of the titer for complement-fixing antibody from 1:< 16 to 1:256. CMV could be isolated from the urine. Investigations for other etiological factors were negative, and we assumed a connection between the cytomegalovirus infection and the myocardial involvement.

Infectious mononucleosis and mononucleosis syndromes

Infectious mononucleosis (IM) and cytomegalovirus (CMV) mononucleosis are caused by a primary infection with related viruses, Epstein-Barr virus (EBV) and CMV. Despite the similarity of clinical manifestations, basic differences exist: (1) The heterophil antibody (HA) response is absent in CMV mononucleosis, whereas it is present in IM. (2) In IM atypical lymphocytosis reflects proliferation of B cells early and of T cells later in the disease course; in CMV mononucleosis the situation appears complex. (3) In blood, EBV is restricted to B lymphocytes, whereas CMV is found in polymorphonuclear and mononuclear leukocytes. (4) Complications of CMV mononucleosis such as hepatitis and pneumonitis may be due to virus cytopathic effect in target organs. Prominent tonsillopharyngitis with adenopathy, and visceral complications of IM are related to lymphoproliferation which is self-limited except in males with a rare familial defect in defense against EBV. Immune complex-mediated pathology may occur in both diseases. (5) CMV is frequently transmitted to a fetus in utero or to an infant during or after birth, and this occasionally leads to severe cytomegalic inclusion disease; vertical transmission of EBV appears to be exceptional. (6) Secondary EBV infections are associated with certain malignancies whereas such an association has not been recognized in the case of CMV. Toxoplasma gondii is another cause of HA-negative mononucleosis. Its complications in the heart, in skeletal muscle and in the central nervous system are related to direct invasion by the parasite. Cellular immunity plays an important role in defense against all three agents.

Disseminated cytomegalic inclusion disease in an adult with cirrhosis of liver and review of literatures

We reported a 44 year old man with micronodular cirrhosis who eventually died from massive hematemesis and melena. At postmortem studies, there were disseminated cytomegalic inclusion bodies detected in various organs. In liver, intranuclear inclusion bodies were observed in cirrhotic liver. We discussed here possible pathogenesis of CMV (cytomegalovirus) infection in adults, in reviewing literatures.

Cytomegalovirus hepatitis in an artificial kidney unit

Serum hepatitis is a dreaded risk in connection with regular dialysis treatment (RDT). Liver damage, however, can be cuased by other diseases, such as infection with cytomegalovirus (CMV). Two cases in our artificial kidney unit revealed signs of liver damage with increased liver enzyme activity. Case 1, a woman, was on RDT after an unsuccessful renal transplantation, and Case 2, a man, belonged to the staff. Serum hepatitis was initially suspected in both cases, but repeated examinations of the sera revealed no hepatitis B antigen or antibodies (HbAg and HbAb). Later on, both showed a significant increase in antibodies in complement fixations reaction (CF) to CMV-antigen. CMV could be isolated from urine in Case 2. Case 1 had been bilaterally nephrectomized. The symptoms (tiredness, muscle pain and headache) and the course of the disease were mild in both cases and liver enzymes became normal within 1-2 weeks. Twenty out of 31 examined patients and staff had antibodies in CF to CMV-antigen, but in none was there any significant increase. The source of infection may have been transfusion of fresh blood in Case 1, but in Case 2 no particular source could be suspected. Thus, in liver damage CMV-infection may be an etiological alternative. In routine work at artficial kidney unite patients and personnel are regularly examined in respect of bilirubin, liver enzymes, HbAg and HbAb in serum. We recommend also examination of serum for antibodies in CF to CMV-antigen. Until a firm differential diagnosis has been established the patient should be isolated and the dialysis equipments used only by that patient.

Smooth-muscle antibodies and other tissue antibodies in cytomegalovirus infection

Smooth-muscle antibodies (SMA) were present in 16% of sixty-three patients with cytomegalovirus (CMV) antibodies in serum and absent in forty CMV antibody-negative blood donors (P = 0-005). The SMA were of the IgG and IgM class, while no IgA antibodies were found. In patients with CMV infection, SMA, mainly of the IgM class, were present in the early stages of the disease, and the titre decreased faster than the complement-fixing CMV antibody titre. Anti-nuclear antibodies (ANA) were also found more often in CMV antibody-positive sera than in CMV antibody-negative sera, and ANA were usually present in sera which also contained SMA. Parietal cell antibodies, mitochondrial antibodies and other cytoplasmic antibodies did not occur more frequently in CMV antibody-positive than in CMV antibody-negative sera.

Clinically evident, non-terminal infections with herpesviruses and the wart virus in immunosuppressed renal allograft recipients

The clinical incidence of herpes simplex lesions, herpes zoster, cytomegalovirus infection, and warts has been determined in a group of renal allograft recipients. Herpes simplex lesions appeared to be no more common after transplantation than before in those patients subject to recurrent attacks. Among 74 patients there were seven cases of herpes zoster and seven serologically proved cases of cytomegalovirus infection with clinical manifestations. The incidence of warts increased with length of time after transplantation, 42% of patients being affected more than one year after transplantation. All of the viral infections studied behaved as in healthy adults, and serious illness, dissemination, wide-spread lesions, and complications were not seen. No factors other than immunosuppression and steroid therapy could be identified with certainty as predisposing to these infections.