Severe systemic cytomegalovirus infection in an immunocompetent patient outside the intensive care unit: a case report

From Bedside to Diagnosis: The Role of Ocular Fundus in Systemic Infections

In this comprehensive review, we delve into the significance of the ocular fundus examination in diagnosing and managing systemic infections at the bedside. While the utilization of advanced ophthalmological diagnostic technologies can present challenges in bedside care, especially for hospitalized patients confined to their beds or during infection outbreaks, the ocular fundus examination often emerges as an essential, and sometimes the only practical, diagnostic tool. Recent discussions have highlighted that the role of an ocular fundus examination might not always be advocated as a routine diagnostic procedure. With this context, we introduce a decision tree tailored for assessing the ocular fundus in inpatients with systemic infections. We also present an overview of systemic infections that impact the eye and elucidate key signs detectable through a bedside ocular fundus examination. Targeted primarily at non-ophthalmology clinicians, this review seeks to offer a comprehensive insight into a multifaceted approach and the enhancement of patient clinical outcomes.

The Overlooked Agent: Cytomegalovirus Colitis in an Immunocompetent Patient

Cytomegalovirus (CMV) colitis is usually associated with immunosuppressed patients, which by the classic definition are individuals who have immunosuppressed associated conditions (human immunodeficiency virus [HIV], oncology diseases, inflammatory bowel disease, transplant patients) or who are submitted to immunosuppressing therapies (for instance, corticosteroids, chemotherapeutic agents or immunomodulation therapies). In immunocompetent patients, this diagnosis tends to be often missed, leading to a delay in initiating proper management. We present a case of a 91-year-old woman that was diagnosed with CMV colitis without any identified formal immunocompromising factors. We intend to highlight the need to review the definition of an immunosuppressed individual and emphasize that CMV colitis should be considered in the differential diagnosis, especially in elderly patients and those with underlying conditions that can possibly affect their immune status, since prompt diagnosis and treatment are essential and influence the prognosis.

[Severe cytomegalovirus-associated protein losing gastropathy in an immunocompetent adult]

INTRODUCTION

Clinical expression of cytomegalovirus (CMV) infection is numerous and depends on the immune status of the host. In immunocompromised patients, CMV disease corresponds to reactivation of the virus with tissue damage responsible for significant morbidity and mortality. In immunocompetent adults, primary CMV infection is usually asymptomatic but may rarely result in severe organ damage.

OBSERVATION

We report the case of a 28-year-old man, considered immunocompetent and without medical history, presenting with a primary CMV infection revealed by a severe protein-losing gastroenteropathy (serum albumin level: 18.9g/L). The CT scan showed a gastro-duodeno-jejuno-ileitis pattern. Upper intestinal endoscopy revealed diffuse ulcerated and congestive gastritis predominantly in the fundus. Histological analysis of the biopsies showed no viral inclusion and no immunohistochemical staining reaction, but a high viral load (5.61 log). Treatment was symptomatic associated with anticoagulation due to the major hypoalbuminemia. The patient slowly recovered, and normal clinical examination and blood tests were observed two months after the onset of symptoms.

CONCLUSION

Severe CMV organ involvement in the immunocompetent patient is very rare but potentially serious. Digestive involvement complicated by exudative enteropathy is possible. Evolution is usually favorable without the need for antiviral treatment.

Clinical Features and Dynamics of T Cells-Related Markers in Immunocompetent Patients with Cytomegalovirus Hepatitis

AIM

Cytomegalovirus (CMV) can cause hepatitis, encephalomyelitis, and pneumonitis in immunocompromised patients. In contrast, CMV infection of immunocompetent patients can lead to the development of infectious mononucleosis and is typically self-limiting; severe complications are rare. We evaluated the pathophysiology and immunological aspects of CMV hepatitis in recently immunocompetent adult patients.

METHODS

We examined the clinical features and outcomes of 47 adult immunocompetent patients with CMV hepatitis (29 men, 18 women; mean age, 34 ± 11 years) from January 2005 to August 2019 treated in our hospital. We also assayed T-cell activation to evaluate the immune responses in these patients.

RESULTS

Fever (74.5%), hepatosplenomegaly (74.5%), sore throat (36.2%), headache (31.9%), abdominal pain (27.7%), lymphadenopathy (23.4%), and skin rash (6.4%) were present at admission. Complications included gastrointestinal injury (25.5%), neuropathy (4.3%), thrombocytopenia (2.1%), and splenic infarction (2.1%). All patients had a good clinical course without liver failure or transition to chronic liver injury. The time to recover from liver injury ranged from 12 to 142 days (mean, 43.4 ± 28.7 days). The serum sIL-2R level, which reflects T-cell activation, was transiently elevated and correlated with the extent of hepatic inflammation.

CONCLUSIONS

CMV hepatitis in immunocompetent individuals has a satisfactory outcome, but occasionally results in complications in other organs. The sIL-2R level has potential as a surrogate marker of hepatic inflammation in immunocompetent patients with CMV hepatitis.