Thrombosis associated with acute cytomegalovirus infection: a meta-analysis

Fatal attractions that trigger inflammation and drive atherosclerotic disease

BACKGROUND

Atherosclerosis is the salient, underlying cause of cardiovascular diseases, such as arrhythmia, coronary artery disease, cardiomyopathy, pulmonary embolism and myocardial infarction. In recent years, atherosclerosis pathophysiology has evolved from a lipid-based to an inflammation-centric ideology.

METHODS

This narrative review is comprised of review and original articles that were found through the PubMed search engine. The following search terms or amalgamation of terms were used: "cardiovascular disease," "atherosclerosis," "inflammation," "GRP78," "Hsp60," "oxidative low-density lipoproteins," "aldehyde dehydrogenase," "β2-glycoprotein," "lipoprotein lipase A," "human cytomegalovirus." "SARS-CoV-2," "chlamydia pneumonia," "autophagy," "thrombosis" and "therapeutics."

RESULTS

Emerging evidence supports the concept that atherosclerosis is associated with the interaction between cell surface expression of stress response chaperones, including GRP78 and Hsp60, and their respective autoantibodies. Moreover, various other autoantigens and their autoantibodies have displayed a compelling connection with the development of atherosclerosis, including oxidative low-density lipoproteins, aldehyde dehydrogenase, β2-glycoprotein and lipoprotein lipase A. Atherosclerosis progression is also concurrent with viral and bacterial activators of various diseases. This narrative review will focus on the contributions of human cytomegalovirus as well as SARS-CoV-2 and chlamydia pneumonia in atherosclerosis development. Notably, the interaction of an autoantigen with their respective autoantibodies or the presence of a foreign antigen can enhance inflammation development, which leads to atherosclerotic lesion progression.

CONCLUSION

We will highlight and discuss the complex role of the interaction between autoantigens and autoantibodies, and the presence of foreign antigens in the development of atherosclerotic lesions in relationship to pro-inflammatory responses.

Lipid-binding antiphospholipid antibodies: significance for pathophysiology and diagnosis of the antiphospholipid syndrome

The antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of pathogenic antiphospholipid antibodies (aPL). Since approximately 30 years ago, lipid-binding aPL, which do not require a protein cofactor, have been regarded as irrelevant for APS pathogenesis even though anticardiolipin are a diagnostic criterion of APS. In this review, we will summarize the available evidence from in vitro studies, animal models, and epidemiologic studies, which suggest that this concept is no longer tenable. Accordingly, we will only briefly touch on the role of other aPL in APS. This topic has been amply reviewed in detail elsewhere. We will discuss the consequences for laboratory diagnostics and future research required to resolve open questions related to the pathogenic role of different aPL specificities.

Cerebral venous sinus thrombosis secondary to acute cytomegalovirus infection

Background

Cerebral venous sinus thrombosis (CVST) is a potentially life-threatening disorder with a number of causes, including viral infections.

Case presentation

A 25-year-old female patient presented with a non-specific febrile illness, headache and hepatitis. She was found to have right transverse sinus and cortical venous thrombosis in addition to acute systemic Cytomegalovirus (CMV) infection. She responded well to anticoagulation with warfarin for 6 months. CMV infection was treated conservatively.

Conclusion

CVST is an increasingly prevalent condition often presenting with headache, focal neurological deficits and seizures. Despite extensive investigations, often no specific cause is found. CMV is a ubiquitous virus that can present with a non-specific febrile illness or a variety of organ dysfunction. CMV has been shown to be associated with predominantly venous thrombosis, most commonly lower limb deep venous thrombosis, pulmonary embolism and splanchnic vein thrombosis. The risk is highest in immunocompromised patients, though most patients are immunocompetent. There have been few reports of CVST related to CMV and all of these with a more tenuous link to acute CMV infection. Clinicians should be aware of this link, particularly in those who have CVST in the context of a febrile illness, or immunocompromised patients.

Renal, splenic, and mesenteric artery thrombosis in the setting of cytomegalovirus infection of an immunocompromised patient: a case report

We present a case report of an immunocompromised adult with cytomegalovirus infection and APLA positivity complicated by multiple large arterial thrombi. This is a rare presentation as most of the cases reported earlier have been of venous thrombosis, thus demonstrating propensity of CMV to induce arterial thrombosis either directly or indirectly.

Mesenteric venous thrombosis

Mesenteric vein thrombosis (MVT) is a rare condition that can present acutely, subacutely, or chronically. MVT can be isolated or within a splanchnic thrombosis (spleno-porto-mesenteric). Symptomatic cases usually present as nonspecific abdominal pain, with or without signs of intestinal ischemia, and the diagnosis is usually made by imaging test (abdominal CT or MRI) in patients with high clinical suspicion. An early clinical-surgical approach is recommended to screen those patients with warning signs and who benefit from an exploratory laparotomy in addition to anticoagulant treatment, which is the cornerstone of medical treatment. MVT is usually associated with prothrombotic states, with hematological disorders (myeloproliferative syndromes and/or JAK2 gene mutations) being of special clinical relevance. On the other hand, the 5-year survival rate is 70-82% and early overall 30-day mortality from MVT can reach 20-32%.

Venous thromboembolism in viral diseases: A comprehensive literature review

Venous thromboembolism (VTE) is known to be a common respiratory and/or cardiovascular complication in hospitalized patients with viral infections. Numerous studies have proven human immunodeficiency virus infection to be a prothrombotic condition. An elevated VTE risk has been observed in critically ill H1N1 influenza patients. VTE risk is remarkably higher in patients infected with the Hepatitis C virus in contrast to uninfected subjects. The elevation of D-dimer levels supported the association between Chikungunya and the Zika virus and the rise of clinical VTE risk. Varicella-zoster virus is a risk factor for both cellulitis and the consequent invasive bacterial disease which may take part in thrombotic initiation. Eventually, hospitalized patients infected with the coronavirus disease of 2019 (COVID-19), the cause of the ongoing worldwide pandemic, could mainly suffer from an anomalous risk of coagulation activation with enhanced venous thrombosis events and poor quality clinical course. Although the risk of VTE in nonhospitalized COVID-19 patients is not known yet, there are a large number of guidelines and studies on thromboprophylaxis administration for COVID-19 cases. This study aims to take a detailed look at the effect of viral diseases on VTE, the epidemiology of VTE in viral diseases, and the diagnosis and treatment of VTE.

Diagnostic Challenges in Pulmonary Embolism in Young Adults: Thrombosis Associated With Cytomegalovirus and Mycoplasma pneumoniae

A 23-year-old man presented with a fever, shaking chills, headaches, nausea, and a dry cough. Investigations showed lymphocytic leukocytosis with atypical lymphocytes in a blood smear. Liver function test results, D-dimer concentrations, and fibrin degradation product concentrations were greatly elevated. Computed tomography of the whole body with contrast showed hepatosplenomegaly with splenic infarction and bilateral pulmonary embolism without deep vein thrombosis. Cytomegalovirus (CMV) immunoglobulin M, and serum CMV pp65 antigenemia were positive, and serum Mycoplasma pneumoniae (M. pneumoniae) antibody was also highly positive. These results suggested the diagnosis of co-infection of CMV and M. pneumoniae complicated by systemic arteriovenous thrombosis, which resulted in pulmonary embolism and splenic infarction. After he started edoxaban tosilate hydrate for the thrombosis, his symptoms resolved in a few days. To the best of our knowledge, this is the first case of co-infection of CMV and M. pneumoniae leading to pulmonary embolism and splenic infarction.

Cytomegalovirus-Associated Gianotti-Crosti Syndrome in 28-Year-Old Immunocompetent Patient

Gianotti-Crosti syndrome is a cutaneous eruption that occurs rarely in adults. It mostly concerns pediatric population and immunocompromised patients. Cytomegalovirus has already been described as one etiology of Gianotti-Crosti acrodermatitis in children and bone-marrow transplanted patients. Here, we present a Cytomegalovirus-associated Gianotti-Crosti syndrome in a 28-year-old immunocompetent female patient diagnosed in CHU Amiens-Picardie (Amiens, France). This type of case has never been shared in literature before. This rare complication of Cytomegalovirus infection indirectly led to disruption of anticoagulant treatment and thromboembolic incident that could have been fatal.

Cytomegalovirus infection is a risk factor for venous thromboembolism in ANCA-associated vasculitis

BACKGROUND

Venous thromboembolism (VTE) is a common complication in patients with anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) and confers significant morbidity and mortality. Both acute and past cytomegalovirus (CMV) infection have been identified as risk factors for VTE in immunocompetent and immunosuppressed individuals. Here, we examine whether past exposure to CMV is a risk factor for VTE amongst patients with AAV.

METHODS

We retrospectively analysed outcomes of patients with a new diagnosis of AAV from a UK cohort. All confirmed cases of VTE where CMV IgG serology was available were recorded. Retrospective collection of the same data for patients at a North American centre was used as a validation cohort.

RESULTS

VTE was common with 12% of patients from the study cohort (total 259 patients) developing an event during the median follow-up period of 8.5 years of which 60% occurred within the first 12 months following diagnosis. Sixteen percent of CMV seropositive patients developed a VTE compared with 5% of patients who were seronegative (p = 0.007) and CMV seropositivity remained an independent predictor of VTE in multivariable analysis (HR 2.96 [1.094-8.011] p = 0.033). CMV seropositivity at diagnosis was confirmed as a significant risk factor for VTE in the American validation cohort (p = 0.032).

CONCLUSIONS

VTE is common in patients with AAV, especially within the first year of diagnosis. Past infection with CMV is an independent risk factor associated with VTE in AAV.

Genetic Predisposition of Anti-Cytomegalovirus Immunoglobulin G Levels and the Risk of 9 Cardiovascular Diseases

Background

Accumulating evidence has indicated that persistent human cytomegalovirus (HCMV) infection is associated with several cardiovascular diseases including atherosclerosis and coronary artery disease. However, whether there is a causal association between the level of anti-HCMV immune response and the risk of cardiovascular diseases remains unknown.

Methods

Single-nucleotide polymorphisms associated with anti-cytomegalovirus immunoglobulin (Ig) G levels were used as instrumental variables to estimate the causal effect of anti-cytomegalovirus IgG levels on 9 cardiovascular diseases (including atrial fibrillation, coronary artery disease, hypertension, heart failure, peripheral artery disease, pulmonary embolism, deep vein thrombosis of the lower extremities, rheumatic valve diseases, and non-rheumatic valve diseases). For each cardiovascular disease, Mendelian randomization (MR) analyses were performed. Inverse variance-weighted meta-analysis (IVW) with a random-effects model was used as a principal analysis. In addition to this, the weighted median approach and MR-Egger method were used for further sensitivity analysis.

Results

In the IVW analysis, genetically predicted anti-cytomegalovirus IgG levels were suggestively associated with coronary artery disease with an odds ratio (OR) of 1.076 [95% CI, 1.009–1.147; p = 0.025], peripheral artery disease (OR 1.709; 95% CI, 1.039–2.812; p = 0.035), and deep vein thrombosis (OR 1.002; 95% CI, 1.000–1.004; p = 0.025). In the further analysis, similar causal associations were obtained from weighted median analysis and MR-Egger analysis with lower precision. No notable heterogeneities and horizontal pleiotropies were observed (p > 0.05).

Conclusions/Interpretation

Our findings first provide direct evidence that genetic predisposition of anti-cytomegalovirus IgG levels increases the risk of coronary artery disease, peripheral artery disease, and deep vein thrombosis.

Multicenter study on recent portal venous system thrombosis associated with cytomegalovirus disease

BACKGROUND & AIMS

Recent non-malignant non-cirrhotic portal venous system thrombosis (PVT) is a rare condition. Among risk factors for PVT, cytomegalovirus (CMV) disease is usually listed based on a small number of reported cases. The aim of this study was to determine the characteristics and outcomes of PVT associated with CMV disease.

METHODS

We conducted a French multicenter retrospective study comparing patients with recent PVT and CMV disease ("CMV positive"; n = 23) to patients with recent PVT for whom CMV testing was negative ("CMV negative"; n = 53) or unavailable ("CMV unknown"; n = 297).

RESULTS

Compared to patients from the "CMV negative" and "CMV unknown" groups, patients from the "CMV positive" group were younger, more frequently had fever, and had higher heart rate, lymphocyte count and serum ALT levels (p ≤0.01 for all). The prevalence of immunosuppression did not differ between the 3 groups (4%, 4% and 6%, respectively). Extension of PVT was similar between the 3 groups. Thirteen out of 23 "CMV positive" patients had another risk factor for thrombosis. Besides CMV disease, the number of risk factors for thrombosis was similar between the 3 groups. Heterozygosity for the prothrombin G20210A gene variant was more frequent in "CMV positive" patients (22%) than in the "CMV negative" (4%, p = 0.01) and "CMV unknown" (8%, p = 0.03) groups. Recanalization rate was not influenced by CMV status.

CONCLUSIONS

In patients with recent PVT, features of mononucleosis syndrome should raise suspicion of CMV disease. CMV disease does not influence thrombosis extension nor recanalization. More than half of "CMV positive" patients have another risk factor for thrombosis, with a particular link to the prothrombin G20210A gene variant.

LAY SUMMARY

Patients with cytomegalovirus (CMV)-associated portal venous system thrombosis have similar thrombosis extension and evolution as patients without CMV disease. However, patients with CMV-associated portal venous system thrombosis more frequently have the prothrombin G20210A gene variant, suggesting that these entities act synergistically to promote thrombosis.

Clinical Characteristics of HIV-Infected Patients with Venous Thromboembolism and Different CD4+ T Lymphocyte Levels

Objective

Methods

Results

Conclusion

Cytomegalovirus-Induced Pericarditis, Pulmonary Embolism, and Transaminitis in an Immunocompetent Patient

Cytomegalovirus (CMV) is a global virus with a high prevalence that usually manifests in immunocompromised patients, with significant morbidity and mortality. Though fairly common in immunocompetent patients admitted in the intensive care units, the infection is usually subclinical. Healthy individuals either have a subclinical course or exhibit a mild mononucleosis-like syndrome. Due to this, little attention has been given to morbidity and mortality that CMV infection may lead to in immunocompetent patients. We report a case of a 55-year-old immunocompetent female with no significant history who was admitted to our medical service with pericarditis, complicated by a right pulmonary embolism. Infectious workup revealed CMV as the cause for the presenting symptoms.

Multiple thrombosis associated with Cytomegalovirus enterocolitis in an immunocompetent patient: a case report

BACKGROUND

Cytomegalovirus (CMV) is reported to have thrombogenic characteristics that activate factor X in vitro and stimulate the production of factor VIII and von Willebrand factor (vWF). Thrombosis associated with CMV infection is prevalent among immunocompromised patients and predominantly presents as a solitary large thrombus in the deep vein, pulmonary artery, splanchnic arteriovenous ducts, or other similar sites. Multiple thrombi, however, are rarely observed in such cases. Here, we report about an immunocompetent man with multiple microthrombi associated with CMV infection.

CASE PRESENTATION

A 72-year-old Japanese man who complained of abdominal pain was hospitalized with multiple colonic stenosis. He was later diagnosed with CMV enterocolitis and treated with ganciclover from Day 27 post-admission. During hospitalization, the patient developed thrombi in his fingers. He was initially treated with anticoagulant therapy (rivaroxaban); however, the therapy was discontinued owing to a prolonged activated thromboplastin time and an elevated international normalized ratio of prothrombin time. Instead, vitamin K and fresh-frozen plasma were administered. Nevertheless, his coagulation profile remained abnormal. Eventually, he developed colonic perforation and had to undergo emergency surgery. An intraoperative specimen showed several microthrombi in the middle and small arteriovenous ducts of his small and large intestines. The patient's coagulopathy improved preoperatively, and his overall condition improved postoperatively. Since the activation of ADAMTS13 was reduced remarkably, the thrombotic tendency was determined to be a thrombotic microangiopathy-like condition owing to increased vWF. We could not attribute the coagulopathy to any other cause except CMV infection; therefore, we concluded that this was a case of multiple thrombosis associated with CMV.

CONCLUSIONS

We present an extremely rare case of a patient with multiple thrombotic microangiopathy-like microthrombosis caused by CMV infection. Our findings suggest that CMV infection may be considered as a differential diagnosis for immunocompetent individuals who present with thrombosis of unspecified cause.

Acute superior mesenteric vein thrombosis in the setting of cytomegalovirus mononucleosis: a case report and review of the literature

Cytomegalovirus is a viral genus of the overarching family Herpesviridae, and is of particular importance because of its relevance to human disease. This association is predominantly due to human cytomegalovirus, a well-studied pathogen. In addition to the mononucleosis syndrome that can occur during acute cytomegalovirus viraemia, this virion has been recurrently implicated as a provoking factor for thromboembolic disease in the published scientific literature. As physicians increasingly forgo extensive laboratory investigation in the setting of clinical hypercoagulability, it has also become evident that in some circumstances whether or not a particular investigation alters clinical management is not necessarily the only important question. Viraemia as a provoking factor for thrombosis stands as such an example. The aim of this Grand Round is to further explore the role of cytomegalovirus as it pertains to thromboembolic disease, especially in the present era of viral-associated thromboembolism.

Donor Graft Cytomegalovirus Serostatus and the Risk of Arterial and Venous Thrombotic Events in Seronegative Recipients After Non-Thoracic Solid Organ Transplantation

BACKGROUND

Cytomegalovirus (CMV) is the most common opportunistic pathogen, following solid organ transplantation (SOT), that leads to direct and indirect effects. The aim of this study was to assess the impact of CMV exposure at transplantation on the rate of posttransplant thrombotic events (TEs).

METHODS

We conducted a retrospective cohort study of patients transplanted at the University of Alberta Hospital between July 2005 and January 2018. We included adult SOT CMV-seronegative recipients at transplantation who received an allograft from either a seropositive donor (D+/R-) or a seronegative donor (D-/R-).

RESULTS

A total of 392 SOT recipients were included: 151 (39%) liver, 188 (48%) kidney, 45 (11%) pancreas, and 8 (2%) other transplants. The mean age was 47 years, 297 (76%) were males, and 181 (46%) had a CMV D+/R- donor. Patients in the CMV D+/R- cohort were slightly older (51 years versus 48 years in the D-/R- cohort; P = .036), while other variables, including cardiovascular risk factors and pretransplant TEs, were not different between groups. Overall, TEs occurred in 35 (19%) patients in the CMV D+/R- group, versus 21 (10%) in the CMV D-/R- group, at 5 years of follow-up (P = .008); the incidence rates per 100 transplant months were 5.12 and 1.02 in the CMV D+/R- and CMV D-/R- groups, respectively (P = .003). After adjusting for potential confounders with a Cox regression model, a CMV D+/R- transplantation was independently associated with an increased risk of a TE over 5 years (adjusted hazard ratio, 3.027; 95% confidence interval, 1.669-5.488).

CONCLUSIONS

A CMV D+/R- transplantation is associated with an increased risk of a TE posttransplantation.

Reactivation cytomegalovirus leading to acute myocardial infarction-A first reported case in an immunocompetent patient

Reactivation of cytomegalovirus (CMV) in immunocompetent patients may lead to increase morbidity and mortality. A clinical suspicion allows timely diagnosis, treatment, and favorable outcome. In a subject without apparent risk factors for acute myocardial infarction (AMI), CMV can be a possibility.

Cytomegalovirus (CMV)-associated portal vein thrombosis in a healthy, immunocompetent man

We present a previously healthy man in his 30s who presented with typical viral prodrome symptoms and worsening abdominal pain. He was found to have portal vein thrombosis, with extensive hypercoagulability workup performed. It was determined that the aetiology of thrombus was secondary to acute cytomegalovirus infection. The patient was started on anticoagulation therapy, with later clot resolution demonstrated on abdominal Doppler ultrasound and abdominal CT scan. Given the atypical presentation of this common virus, we performed a literature review of cytomegalovirus-associated portal vein thrombosis in healthy individuals; we found that most patients present with non-specific symptoms of fever and abdominal pain in the setting of a viral prodrome. This case and literature review suggest physicians must consider cytomegalovirus-associated portal vein thrombosis as a potential diagnosis when patients present with abdominal pain and viral symptoms. The literature highlights the need for a consensus on anticoagulation and antiviral therapy.

Cytomegalovirus-Associated Venous and Arterial Thrombotic Disease

BACKGROUND

Cytomegalovirus (CMV) infection has been associated with venous thromboembolism (VTE) and acute coronary syndromes (ACS).

METHODS

A retrospective study was conducted within the OSF HealthCare System in Peoria, IL. The objectives were to determine the incidence of acute VTE and ACS within one year of CMV testing. The "study group" included patients with positive CMV immunoglobulin M (IgM) or positive CMV polymerase chain reaction (PCR). The "seropositive control" group included patients with positive CMV immunoglobulin G (IgG) and negative IgM. The "seronegative control" group included patients with negative CMV IgG and IgM, or negative PCR.

RESULTS

Within one year of CMV infection, 38 of 379 patients (10.0%) developed VTE in the study group compared to 41 of 1334 patients (3.1%) in the seropositive control and 37 of 1249 (3.0%) in the seronegative control. Adjusting for age and gender, both control groups were less likely to have VTE than the study group within one year (seropositive control: odds ratio (OR) = 0.3, 95% confidence interval (CI) 0.2-0.5, p < 0.0001; seronegative control: OR = 0.4, 95% CI 0.2-0.6, p < 0.0001). ACS was more likely to occur in the study group, with the incidence of 7.7% compared to 4.7% (p < 0.0001) in the seropositive control and 1.9% (p <0.0001) in the seronegative control. Adjusting for age and gender, the seronegative control was less likely to develop ACS than the study group within one year (OR = 0.4, 95% CI 0.2-0.7, p = 0.003).

CONCLUSIONS

This retrospective study demonstrates that CMV infection may be a significant risk factor for VTE and ACS.

Systematic duplex ultrasound screening in conventional units for COVID-19 patients with follow-up of 5 days

OBJECTIVE

COVID-19 patients may develop coagulopathy, which is associated with poor prognosis and high risk of thrombosis. The main objective of this work was to evaluate the prevalence of deep venous thrombosis of lower limbs (DVT) through ultrasonography in patients infected with COVID-19 admitted to conventional units at our hospital with 5 days of monitoring. The secondary objective was to determine if D-dimer levels, body mass index, and C-reactive protein were associated with DVT.

METHODS

A total of 72 patients, with a mean age of 65 ± 12.3 years, infected with COVID-19 were admitted to three conventional units at our institution; 28 patients were women. A COVID-19 diagnosis was made by a transcriptase polymerase chain reaction by means of nasopharyngeal swab or by chest computer tomography without iodine contrast media. Demographics, comorbidities, and laboratory parameters were collected. A preventive anticoagulation treatment was established on admission with low-molecular-weight heparin. A complete venous duplex ultrasound (DU) test of lower limbs was performed on day (D) 0 and D5. A pulmonary computer tomography angiogram with iodine contrast media was required when pulmonary embolism was suspected.

RESULTS

On D0, the DU showed acute DVT in seven patients (9.75%). A pulmonary computer tomography angiogram was performed in 12 patients (16.65%), 3 (25%) of whom had an acute pulmonary embolism. On D0, acute DVT was not significantly associated with C-reactive protein (mean 101 ± 98.6 in the group without DVT vs 67.6 ± 58.4 mg/L, P = .43) or body mass index (27.7 ± 5.04 vs 28.1 ± 2.65 kg/m², P = .54). However, we found a significant association between acute DVT and D-dimer levels (1536 ± 2347 vs 9652 ± 10,205 ng/mL, P < .01). Among the patients included on D0, only 32 had a DU on D5. Forty of them (55.55%) were not examined for the following reasons: 7 (9.7%) were previously diagnosed with venous thromboembolism on D0 and therefore were excluded on D5, 8 (11%) were transferred to the intensive care unit, 10 (14%) were discharged from the hospital, 5 (7%) died, and 10 (13.9%) were excluded because of technical issues. On D5, five (15.6%) patients had acute DVT in addition to those found on D0; three were distal and two proximal despite preventive anticoagulation with low-molecular-weight heparin.

CONCLUSIONS

Hospitalized non-intensive care unit patients with COVID-19 pneumonia have a high frequency of venous thrombotic events justifying screening with DU.

Superior mesenteric vein thrombosis induced by influenza infection: A case report

BACKGROUND

Among the various types and causes of mesenteric ischemia, superior mesenteric vein (SMV) thrombosis is a rare and ambiguous disease. If a patient presents with SMV thrombosis, past medical history should be reviewed, and the patient should be screened for underlying disease. SMV thrombosis may also occur due to systemic infection. In this report, we describe a case of SMV thrombosis complicated by influenza B infection.

CASE SUMMARY

A 64-year-old male visited the hospital with general weakness, muscle aches, fever, and abdominal pain. The patient underwent computed tomography (CT) and was diagnosed with SMV thrombosis. Since the patient’s muscle pain and fever could not be explained by the SMV thrombosis, the clinician performed a test for influenza, which produced a positive result for influenza B. The patient had a thrombus in the SMV only, with no invasion of the portal or splenic veins, and was clinically stable. Anticoagulation treatment was prescribed without surgery or other procedures. The follow-up CT scan showed improvement, and the patient was subsequently discharged with continued oral anticoagulant treatment.

CONCLUSION

This case provides evidence that influenza may be a possible risk factor for SMV thrombosis. If unexplained abdominal pain is accompanied by an influenza infection, examination of an abdominal CT scan may be necessary to screen for possible SMV thrombosis.

High Prevalence of Acquired Thrombophilia Without Prognosis Value in Patients With Coronavirus Disease 2019

Background Recent literature reports a strong thrombotic tendency in patients hospitalized for a coronavirus disease 2019 (COVID-19) infection. This characteristic is unusual and seems specific to COVID-19 infections, especially in their severe form. Viral infections can trigger acquired thrombophilia, which can then lead to thrombotic complications. We investigate for the presence of acquired thrombophilia, which could participate in this phenomenon, and report its prevalence. We also wonder if these thrombophilias participate in the bad prognosis of severe COVID-19 infections. Methods and Results In 89 consecutive patients hospitalized for COVID-19 infection, we found a 20% prevalence of PS (protein S) deficiency and a high (ie, 72%) prevalence of antiphospholipid antibodies: mainly lupus anticoagulant. The presence of PS deficiency or antiphospholipid antibodies was not linked with a prolonged activated partial thromboplastin time nor with D-dimer, fibrinogen, or CRP (C-reactive protein) concentrations. These coagulation abnormalities are also not linked with thrombotic clinical events occurring during hospitalization nor with mortality. Conclusions We assess a high prevalence of positive tests detecting thrombophilia in COVID-19 infections. However, in our series, these acquired thrombophilias are not correlated with the severity of the disease nor with the occurrence of thrombotic events. Albeit the strong thrombotic tendency in COVID-19 infections, the presence of frequent acquired thrombophilia may be part of the inflammation storm of COVID-19 and should not systematically modify our strategy on prophylactic anticoagulant treatment, which is already revised upwards in this pathological condition. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT04335162.

Extracellular Vesicle-Related Thrombosis in Viral Infection

Although the outcomes of viral infectious diseases are remarkably varied, most infections cause acute diseases after a short period. Novel coronavirus disease 2019, which recently spread worldwide, is no exception. Extracellular vesicles (EVs) are small circulating membrane-enclosed entities shed from the cell surface in response to cell activation or apoptosis. EVs transport various kinds of bioactive molecules between cells, including functional RNAs, such as viral RNAs and proteins. Therefore, when EVs are at high levels, changes in cell activation, inflammation, angioplasty and transportation suggest that EVs are associated with various diseases. Clinical research on EVs includes studies on the coagulatory system. In particular, abnormal enhancement of the coagulatory system through EVs can cause thrombosis. In this review, we address the functions of EVs, thrombosis, and their involvement in viral infection.

Young-Onset Ischemic Colitis: A Condition of Elusive Etiology Frequently Associated With Immune Dysregulation

Ischemic colitis (IC) associates with older age, hypertension, and heart disease, among others. Young-onset IC is rare. We aimed to delineate clinical characteristics of young patients (<40 years) with IC. Cases from 1984 to 2017 were re-reviewed. Of the 60 cases available, 52% (n = 31) had histologic features of IC. Fifty-five percent were female with a mean age of 32 (range = 14-40) years. Fifty-eight percent (n = 18) were resections. The most common presentations were diarrhea and abdominal pain. Three teenagers had IC associated with prior surgery, volvulus, and constipation. In the 21- to 40-year group, 43% (n = 12) lacked clinical associations. A second subset (n = 6, 21%) had histories of immune dysregulation (lupus, dermatomyositis, vasculitis) and poorly controlled HIV/AIDS (n = 5, 18%). Smoking and cocaine were endorsed by 1 and 2 patients, respectively. One patient had premature atherosclerosis while another had HMG Co-A lyase deficiency. Vasculitis was identified in 22% of the resections and in none of the biopsies. Nineteen percent of patients died (n = 6) from complications of IC, all treated surgically, including 1 patient previously misdiagnosed as ulcerative colitis; 2 patients died of unrelated causes. While rare before 20 years of age, IC in teenagers relates to mechanical issues and is rare in children. Associations in young adults include immune dysregulation, cocaine and cigarette use, and premature atherosclerosis. Our retrospective cohort had a surgical mortality rate within the range reported by others, highlighting the importance of accurate diagnosis in young individuals.

Environmental Triggers of Autoreactive Responses: Induction of Antiphospholipid Antibody Formation

Antiphospholipid antibodies (aPLs) comprise a diverse family of autoantibodies targeted against proteins with the affinity toward negatively charged phospholipids or protein-phospholipid complexes. Their clinical significance, including prothrombotic potential of anti-cardiolipin antibodies (aCLs), anti-β2-glycoprotein I antibodies (aβ2-GPIs), and lupus anti-coagulant (LA), is well-established. However, the ontogeny of these pathogenic aPLs remains less clear. While transient appearance of aPLs could be induced by various environmental factors, in genetically predisposed individuals these factors may eventually lead to the development of the antiphospholipid syndrome (APS). Since the first description of APS, it has been found that a wide variety of microbial and viral agents influence aPLs production and contribute to clinical manifestations of APS. Many theories attempted to explain the pathogenic potential of different environmental factors as well as a phenomenon termed molecular mimicry between β2-GPI molecule and infection-relevant structures. In this review, we summarize and critically assess the pathogenic and non-pathogenic formation of aPLs and its contribution to the development of APS.

Antiphospholipid antibody syndrome with thrombotic splenic infarcts associated with acute cytomegalovirus infection

INTRODUCTION

We describe a case of acute cytomegalovirus (CMV) infection complicated by acquired antiphospholipid antibodies and splenic thrombi. We discuss the associations between CMV infection and thrombosis risk and correlation with antiphospolipid antibodies.

CASE PRESENTATION

A previously healthy 32-year-old woman is hospitalized for acute abdominal pain and fever and found to have multiple splenic infarcts on an abdominal computed tomography (CT) scan. An infectious work-up is negative except for acute CMV, and a hypercoagulable work-up is only positive for antiphospholipid antibodies. The patient is discharged and placed on anti-coagulation therapy for 6 months.

CONCLUSION

Co-incident thrombosis and antiphospholipid antibody syndrome can occur with acute viral infections, including CMV. We discuss the viral infection-associated increased risk of developing blood clots and antiphospholipid antibodies as being either correlative with or causative of viral-induced thrombosis.

Concomitant Infection With Epstein-Barr Virus and Cytomegalovirus Infection Leading to Portal Vein Thrombosis

BACKGROUND

Portal vein thrombosis (PVT) is well recognized as a complication of hepatic cirrhosis and is likely to be suspected in patients with hypercoagulable syndromes, however, it is rarely recognized as a possibility in otherwise healthy patients with Epstein-Barr virus (EBV) or cytomegalovirus (CMV) infection. We report a case of a healthy 27-year-old man with fever and weight loss who was found to have PVT in the setting of acute EBV and CMV infection.

CASE REPORT

A 27-year-old man with no known medical history presented to the emergency department (ED) for fever for 18 days. Patient reported daily high fevers associated with chills, night sweats, generalized myalgia, nausea with appetite loss, and unquantified weight loss. Vital signs showed temperature of 100.5°F. Patient reported discomfort upon palpation of abdomen on physical examination. There was no lymphadenopathy, cardiac murmur, rash, or jaundice. Laboratory tests revealed titers diagnostic of acute EBV and CMV infection with elevated liver function tests and leukocytosis with lymphocyte predominance (white blood cell count 15,400/μL; 43% atypical lymphocytes). Computed tomography of the abdomen/pelvis with i.v. contrast showed a filling defect in the anterior portal vein. The patient was admitted with the ED diagnosis of PVT secondary to viral infection and was initiated on anticoagulation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although rarely considered, CMV has been associated with PVT in up to 6% of cases, and EBV infection has been implicated as well. Emergency physicians should be aware of this potentially serious complication of these common viral infections and consider imaging modalities to rule out thrombosis, if appropriate.

Rare case of catastrophic antiphospholipid syndrome with spontaneous intracranial haemorrhage

Catastrophic antiphospholipid syndrome (CAPS) is a rare but severe form of antiphospholipid syndrome (APS). The syndrome manifests itself as a rapidly progressive multiorgan failure that is believed to be caused by widespread micro-thrombosis. Seldom does bleeding comanifest with thrombosis. We present a patient with APS who presented with nausea, vomiting and fatigue, and rapidly progressed into multiorgan failure before being diagnosed with CAPS. The clinical course was complicated by an atraumatic intracranial haemorrhage which demanded discontinuation of anticoagulation. The patient was treated with high dose steroid, intravenous immunoglobulin, followed by weekly rituximab infusion. Although the trigger for CAPS was not obvious during her hospital stay, she was diagnosed with acute cytomegalovirus (CMV) infection soon after discharge. In this case report, we explore the differential diagnoses of CAPS, investigate the possibility of CMV infection as a potential trigger, present the therapeutic challenges of anticoagulation and discuss the emerging use of rituximab.

Antiphospholipid Antibodies Overlapping in Isolated Neurological Syndrome and Multiple Sclerosis: Neurobiological Insights and Diagnostic Challenges

Antiphospholipid syndrome (APS) is characterized by arterial and venous thrombosis, pregnancy morbidity and fetal loss caused by pathogenic autoantibodies directed against phospholipids (PL) and PL-cofactors. Isolated neurological APS may represent a significant diagnostic challenge, as epidemiological, clinical and neuroimaging features may overlap with those of multiple sclerosis (MS). In an open view, MS could be considered as an organ-specific anti-lipid (phospholipid and glycosphingolipid associated proteins) disease, in which autoreactive B cells and CD8+ T cells play a dominant role in its pathophysiology. In MS, diverse autoantibodies against the lipid-protein cofactors of the myelin sheath have been described, whose pathophysiologic role has not been fully elucidated. We carried out a review to select clinical studies addressing the prevalence of antiphospholipid (aPL) autoantibodies in the so-called MS-like syndrome. The reported prevalence ranged between 2% and 88%, particularly aCL and aβ2GPI, with predominant IgM isotype and suggesting worse MS prognosis. Secondarily, an updated summary of current knowledge on the pathophysiological mechanisms and events responsible for these conditions is presented. We draw attention to the clinical relevance of diagnosing isolated neurological APS. Prompt and accurate diagnosis and antiaggregant and anticoagulant treatment of APS could be vital to prevent or at least reduce APS-related morbidity and mortality.

Cytomegalovirus infection with pulmonary embolism, splenic vein thrombosis and monoclonal gammopathy of undetermined significance: a case and systematic review

A 62-year-old immunocompetent woman was admitted with cytomegalovirus (CMV) infection, pulmonary embolism, splenic vein thrombosis and monoclonal gammopathy of undetermined significance (MGUS). Anticoagulation therapy was started. Two months later, seroconversion of CMV IgM to IgG was observed, while the monoclonal protein was no longer detectable. This suggests a relationship between acute CMV infection, transient MGUS and thrombosis. In accordance with current best practice guidelines for provoked venous thromboembolism (VTE), anticoagulation therapy could be discontinued after 3 months instead of 6 for unprovoked VTE, thereby reducing unnecessary time at risk of bleeding complications. While the relationships between CMV and both MGUS and thrombosis have been described independently, we are first to describe these three conditions occurring simultaneously.Furthermore, we provide a systematic review on the relation between CMV, MGUS and thrombosis.

Aortic Arch Thrombosis Associated with Fetal Cytomegalovirus Viremia

Cytomegalovirus(CMV) associated thrombosis has been reported sporadically in the medical literature; however, its antenatal scenario has not been documented. We herein present the antenatal, Doppler's ultrasound and magnetic resonance angiographic features of thrombosis in the aortic arch showing extension toward the medial lumen of the brachiocephalic trunk with critical occlusion of the left common carotid artery and left subclavian artery in a term fetus to raise obstetricians'/ neonatologists'/pediatric cardiologists' awareness for the association between CMV viremia and intrauterine thrombosis that caused cerebral injury, neurodevelopmental impairment, and permanent sequela.

Acute cytomegalovirus infection associated with pulmonary embolism treated successfully with rivaroxaban: case report

Severe life-threatening thromboembolism may be caused exclusively by the presence of an acute CMV infection or due to the association of this agent and other thrombogenic factors. We report a case of an immunocompetent young female patient who presented a pulmonary embolism associated with acute CMV infection. The patient did not have any other apparent cause of thrombosis. She was successfully treated with rivaroxaban for 6 months without further episodes. To the best of our knowledge, this is the first report of a pulmonary embolism associated with CMV treated with a direct oral anticoagulant. The current case report calls attention to the importance of signs and symptoms of thromboembolism among patients with CMV. Direct oral anticoagulants can potentially bring the same benefits to treat pulmonary embolism associated with CMV as those observed in patients not infected.

Venous Thrombosis Secondary to Acute Cytomegalovirus Infection in an Immunocompetent Host: Consideration for New Screening Guidelines

Serious thrombotic complications associated with an acute cytomegalovirus (CMV) infection in immunocompromised and immunocompetent patients are becoming increasingly recognized. While typically asymptomatic and self-limiting, an acute CMV infection appears to demonstrate a rare propensity for a vascular thrombosis, such as deep vein thrombosis (DVT), thrombophlebitis, and pulmonary embolism (PE). It remains unclear whether other predisposing factors play a role in its pathogenesis. We report the case of a young, immunocompetent male with extensive lower extremity DVT who was coincidentally found to be CMV-immunoglobulin M (IgM) seropositive. In light of the increasing prevalence of CMV-associated thrombotic events, we reviewed the current literature on its incidence, pathophysiology, clinical features, and thrombophilia screening to consider the possibility of CMV seropositivity as an independent risk factor for vascular events. This may have repercussions for screening guidelines and preventive strategies in those with active CMV infection.

Splenic Infarction: An Under-recognized Complication of Infectious Mononucleosis?

Splenic infarction is a rare complication of infectious mononucleosis. We describe 3 cases of splenic infarction attributed to infectious mononucleosis that we encountered within a 2-month period. We underscore the awareness of this potential complication of infectious mononucleosis and discuss the differential diagnosis of splenic infarction, including infectious etiologies. While symptomatic management is usually sufficient for infectious mononucleosis-associated splenic infarction, close monitoring for other complications, including splenic rupture, is mandated.

Venous thromboembolism related to cytomegalovirus infection: A case report and literature review

RATIONALE

Herein, we present a case of seemingly unprovoked portal vein thrombosis (PVT) occurring in the context of an acute cytomegalovirus (CMV) infection and prolonged debilitating fatigue.

PATIENT CONCERNS

A 46-year-old male airline pilot presented with a 2 week history of abdominal pain, nausea, vomiting, watery diarrhea, and daily recurrent fevers. This was in the context of progressive, debilitating fatigue for 3 months forcing the patient to leave his job.

DIAGNOSES

Computed tomography of the abdomen revealed PVT, which was managed initially by heparin infusion. Cefepime was ordered for broad-spectrum antibiotic management of sepsis and possible septic thrombosis. Further workup exposed elevated transaminases consistent with mild hepatitis without synthetic dysfunction and colonoscopy revealed colitis. A comprehensive evaluation for liver disease was notable for a markedly elevated ferritin level. Spiking fevers and neutrophilia persisted for several days despite empiric antimicrobial treatment, but eventually resolved. The remainder of the workup was negative except for positive CMV IgM titer and viral load. This raised suspicion for a hypercoagulable state caused by CMV hepatitis with CMV-induced PVT. Heparin was transitioned to warfarin at the time of discharge.

INTERVENTIONS

Given the patient's immunocompetent state and resolution of fevers, antiviral therapy for CMV infection was not initiated.

OUTCOMES

The patient continued to improve with a normalization of the serum ferritin level and anticoagulation therapy was stopped after 6 months.

LESSONS

There is mounting support for infectious causes of venous thromboembolism (VTE) based on existing molecular biology and clinical research. Meta-analysis of existing data showed that between 1.9% and 9.1% of patients hospitalized with VTE had concurrent acute CMV infection. Theoretical mechanisms for this association include transient formation of antiphospholipid antibodies, transient formation of antibodies targeting CMV capsule phospholipids with procoagulant properties, and direct infection of the endothelial cells. We hope this case will serve as a reminder to consider CMV as a transient cause of PVT and VTE, particularly in light of 2016 guidelines for unprovoked VTE recommending lifelong anticoagulation. We also plan to prospectively study the association of unprovoked VTE and acute CMV infection in our own hospital system.

Splenic Infarct and Pulmonary Embolism as a Rare Manifestation of Cytomegalovirus Infection

Cytomegalovirus (CMV) is a type of herpes infection that has a characteristic feature of maintaining lifelong latency within the host cell. CMV manifestations can cover a broad spectrum from fever to as severe as pancytopenia, hepatitis, retinitis, meningoencephalitis, Guillain-Barre syndrome, pneumonia, and thrombosis. Multiple case reports of thrombosis associated with CMV have been reported. Deep vein thrombosis or pulmonary embolism is more common in immunocompetent patients while splenic infarct is more common in immunocompromised patients. However, here we report a female patient on low-dose methotrexate for rheumatoid arthritis who presented with both pulmonary embolism and splenic infarct.

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.

Acute Cytomegalovirus (CMV) Infection Associated with Hemophagocytic Lymphohistiocytosis (HLH) in an Immunocompetent Host Meeting All Eight HLH 2004 Diagnostic Criteria

Hemophagocytic lymphohistiocytosis (HLH) is a rare and often deadly syndrome characterized by severe inflammation and cytokine dysregulation. The disease is defined by the HLH-2004 criteria, requiring five of eight findings, and is further differentiated into either primary or secondary causes. Primary HLH tends to be of genetic etiology, while secondary HLH results from other insults such as infection. Secondary HLH is most commonly associated with viral infections in immunocompromised patients. Acute cytomegalovirus (CMV) associated HLH in the immunocompetent host is exceedingly rare and only documented in four case reports to date. We describe the fifth documented case of CMV-associated HLH in an immunocompetent patient, and furthermore, we demonstrate that this patient is the first published case of its type to satisfy all eight of HLH-2004 criteria.

Case report: acute portal vein thrombosis associated with acute cytomegalovirus infection in an immunocompetent adult

Cytomegalovirus (CMV) infection is usually asymptomatic and self-limiting in healthy individuals, but significant complications can develop in immunosuppressed patients. Venous or arterial thromboembolic phenomena are uncommon yet very serious complications of CMV infection. Most published reports describe immunosuppressed patients, but thrombotic events in CMV-infected immunocompetent individuals may also occur. We describe the case of an immunocompetent young man with acute CMV hepatitis that was complicated with portal vein thrombosis (PVT). We also review the literature regarding the association between PVT and CMV in immunocompetent patients. Thromboembolism is an underestimated but significant complication of acute CMV infection. Several local and systemic factors are involved in the pathogenesis of acute PVT. This case emphasizes the central role of ultrasound in its diagnosis and the potentially serious complications that can occur in immunocompetent individuals with no other prothrombotic risk factors.

[Primary infection with cytomegalovirus: An infectious cause of splenic infarction]

INTRODUCTION

Cytomegalovirus-associated thrombosis has been extensively reported in the medical literature, mainly in immune-compromised patients. However, the association with splenic infarcts has rarely been reported.

CASE REPORT

We report a 32-year-old Caucasian and immunocompetent woman who presented with a splenic infarction during a primary infection with CMV. The differential diagnostic ruled out embolic, hematologic, gastrointestinal and coagulation disorders. The outcome was favorable with symptomatic treatment.

CONCLUSION

A primary infection with CMV must be added to the diagnostic work-up in the presence of a febrile splenic infarction, especially when it is associated with a biological mononucleosis reaction.