Cytomegalovirus acute infection with pulmonary involvement in an immunocompetent patient

Cytomegalovirus pneumonia with intermittent pulmonary hemorrhage leading to asphyxia death: a case report and literature review

Neonatal pulmonary hemorrhage is a late manifestation of various diseases. Premature delivery and low body weight are frequently observed as high-risk factors, characterized by acute onset, rapid progression, and high mortality rates. Pulmonary hemorrhage caused by cytomegalovirus infection in newborns with normal immune function is a rare occurrence. This case report focuses on a term neonate with normal birth weight who presented solely with nasal obstruction shortly after birth. However, 4 days after birth, the newborn experienced a sudden onset of blood gushing from both the mouth and nasal cavity. The patient was diagnosed with gastrointestinal bleeding, neonatal pneumonia and neonatal lung consolidation. And he was discharged after ten days of symptomatic treatment. However, upon returning home, the patient experienced a sudden onset of bleeding from the mouth and nose, leading to his untimely demise. Subsequent autopsy revealed the presence of pulmonary hemorrhage in newborn, which presented as interstitial pneumonia. The cause of pulmonary hemorrhage is cytomegalovirus infection. This case emphasizes the importance of pediatricians enhancing their skills in differentiating pulmonary hemorrhage, especially from cytomegalovirus pneumonia.

Secretion of IFN-γ by specific T cells in HCMV infection

One major risk for recipients undergoing allogeneic hematopoietic stem cell transplants (allo-HSCTs) is infection with the human cytomegalovirus (HCMV). For HCMV treatment, it is especially crucial to be able to differentiate between recipients who are at high risk of reactivation and those who are not. In this study, HCMV-DNA was collected from 60 HLA-A*02 allo-HSCT recipients before and after transplantation. After transplantation, the release of interferon (IFN)-γ by T cells specific to HCMV was assessed using the enzyme-linked immunospot assay (ELISPOT). The results show that the median viral load (VL) was significantly higher in the HCMV persistent-infection group compared to the non-persistent-infection group (p = 0.002), and that the late-infection rate was considerably higher in the high-VL group compared to the low-VL group (p = 0.014). The uninfected group had a considerably higher median IFN-γ spot-forming cell (SFC) count than the persistent-infection group (p = 0.001), and IFN-γ SFC counts correlated negatively and linearly with VLs (r = -0.397, p = 0.002). The immune-response groups showed significantly difference in median VL (p = 0.018), and the high immune response group had a reduced late-infection rate than the no/low immune response groups (p = 0.049). Our study showed that allo-HSCT recipients with a high VL at an early transplantation stage were at high risk for late HCMV infection. Further HCMV reactivation can be prevented by HCMV-specific T cells secreting enough IFN-γ.

Cytomegalovirus Pneumonia in a Patient with Down Syndrome

Down syndrome (DS) is a chromosomal disorder due to the presence of an additional chromosome 21 that causes intellectual deficit and physical anomalies and predisposes patients to develop infections throughout their lives. Pneumonias are more serious in patients with DS, requiring hospitalization, and they represent an important cause of mortality in this population. Cytomegalovirus (CMV) causes widespread and serious infections in immunocompromised individuals, affecting the respiratory tract and, when causing interstitial pneumonia, associated with a high mortality rate. However, CMV-induced pneumonia is not reported in DS patients. The prevalence and severity of CMV respiratory infections in subjects with DS is unknown. This case describes a 50-year-old female patient with DS who developed extensive bilateral pneumonia with severe respiratory failure which required hospitalization in intensive care, intubation, and mechanical ventilation after approximately 10 days of empiric antibiotic and anitimycotic therapy for fever, cough, and dyspnea. The patient was diagnosed with CMV pneumonia and recovered after treatment with ganciclovir. To the best of our knowledge, this is the first reported case of CMV pneumonia in a patient with DS. This case aims to highlight that CMV pneumonia in individuals with DS can be a life-threatening condition. It also clarifies the importance of early diagnosis of infections from opportunistic pathogens such as CMV to ensure timely and efficient treatment.

Primary Cytomegalovirus Pneumonia Successfully Treated with Corticosteroid Therapy and Valganciclovir

Cytomegalovirus infection is typically asymptomatic in immunocompetent individuals. A 26-year-old woman was admitted to our hospital with a fever and breathlessness. Chest computed tomography (CT) revealed bilateral diffuse reticulation and nodules. Laboratory investigations showed atypical lymphocytosis and increased transaminases. She was treated with corticosteroid pulse therapy because of acute lung injury, and her clinical condition improved. Based on the presence of cytomegalovirus antibodies, antigen, and polymerase chain reaction findings, she was diagnosed with primary cytomegalovirus pneumonia and treated with valganciclovir. Primary cytomegalovirus pneumonia is very rare in immunocompetent individuals. The efficacy of corticosteroid and valganciclovir against cytomegalovirus pneumonia in this patient is noteworthy.

Pulmonary cytomegalovirus infection: A case report and systematic review

BACKGROUND

Cytomegalovirus (CMV) is a common virus that can cause the first infection in childhood or adolescence and reactivate later in life due to immunosuppression. CMV pneumonia is a rare illness in immunocompetent patients but is one of the most significant opportunistic infections in immunocompromised patients.

AIM

To report a case and review published cases of pulmonary CMV infection in both immunocompromised and immunocompetent patients.

METHODS

We conducted a systematic search on the MEDLINE (PubMed) database, without date or language restrictions, to identify relevant studies using Medical Subject Headings and Health Science Descriptors. We manually searched the reference lists of the included studies. Simple descriptive analysis was used to summarize the results.

RESULTS

Our search identified 445 references, and after screening, 43 studies reporting 45 cases were included in the final analysis, with 29 (64%) patients being immunocompromised and 16 (36%) being immunocompetent. Fever (82%) and dyspnea (75%) were the most common clinical findings. Thoracic computed tomography showed bilateral ground-glass opacities, a relevant differential diagnosis for severe acute respiratory syndrome coronavirus 2 infection. The majority of patients (85%) received antiviral therapy, and 89% of patients recovered, while 9% of patients died.

CONCLUSION

CMV pneumonia should be considered as a differential diagnosis for coronavirus disease 2019 pneumonia, especially in immunocompromised patients. Clinicians should be aware of the clinical presentation, management, and outcomes of CMV pneumonia to guide appropriate treatment decisions.

Hemophagocytic Lymphohistiocytosis Associated With Cytomegalovirus Infection: 5 Cases and a Systematic Review of the Literature

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder characterized by an uncontrolled, persistent, hyperimmune response. It can be triggered by an infectious, neoplastic, or autoimmune event. The involvement of cytomegalovirus (CMV) in the onset of HLH is subject to debate, and the epidemiology of CMV-associated HLH (HLH-CMV) remains poorly characterized. We identified 5 cases of HLH-CMV in our hospital, systematically searched the PubMed database for publications on HLH-CMV, and reviewed 57 publications with a total of 67 cases of HLH-CMV. Only 48 patients (71.6%) were immunodeficient, suggesting that HLH-CMV can occur in immunocompetent patients. The major cause of underlying immunodepression (51%) was inflammatory bowel disease (mainly treated with azathioprine). CMV infection was nearly always symptomatic, and lung involvement was frequent (31 cases). Fifty-five patients recovered. Nineteen patients were treated for CMV infection only and had a good outcome, suggesting that antiviral drugs might be the cornerstone of HLH-CMV treatment.

Cytomegalovirus pneumonia in a background of central nervous system tuberculosis

A 32‐year‐old patient, who was on treatment for tuberculous meningitis complicated with venous sinus thrombosis, was referred to the medical unit as he developed new onset fever, cough and shortness of breath. He was in respiratory distress and needed intubation. Investigations revealed elevated liver enzymes, leukopenia, spherocytosis and lower lobe predominant consolidations and diffuse nodules in the high‐resolution computed tomography. He was suspected to have cytomegalovirus (CMV) pneumonia with the above results, and further investigations revealed an extremely elevated CMV viral load. He was treated with ganciclovir followed by valganciclovir for a total of 42 days resulting in a complete recovery. Liver functions resolved with anti‐viral treatment, and he was started on full anti‐tuberculosis (TB) treatment. Further investigations did not reveal evidence of immunosuppression. Association of CMV and TB is explained genetically, although clinical association is rarely described. The presence of either infection should lead to higher degree of suspicion of the respective other condition in relevant clinical setting.

A rare case of cytomegalovirus causing respiratory failure and a large pericardial effusion

Cytomegalovirus (CMV) infection is asymptomatic in the majority of immunocompetent patients. However, it can cause severe presentations, particularly in patients who are immunocompromised. We are reporting a rare association between respiratory failure secondary to cavitary pneumonia and a large pericardial effusion due to CMV infection in a patient with human immunodeficiency virus. The patient presented with hypoxic respiratory failure and a large pericardial effusion at risk of tamponade. After extensive investigation, the sole pathogen identified in the patient’s bronchoalveolar lavage and pericardial fluid was CMV.

Cytomegalovirus Pulmonary Involvement in an Immunocompetent Adult

Introduction

Cytomegalovirus (CMV) is a linear double-stranded DNA virus that may cause severe and potentially fatal infection in immunocompromised hosts. In immunocompetent individuals, the infection is typically mild or asymptomatic. However, in the last years, some cases of severe cytomegalovirus infection in immunocompetent individuals have been described. Clinical Presentation. The authors present a male patient aged 42 years, without specific medical history, who presented a 15-day history of fever, headache, night sweats, odynophagia, and bilateral otalgia, without improvement after four days of therapy with amoxicillin/clavulanic acid. Blood count and biochemistry were performed with liver cytolysis pattern. Chest teleradiography showed diffuse interstitial infiltrate. Thoracic CT scan revealed areas in a ground glass with a cross-linking component in the left and right upper lung lobes compatible with an inflammatory/infectious process. Blood serology was positive for CMV IgG and IgM. The detection on blood and bronchoalveolar lavage of CMV DNA by polymerase chain reaction (PCR) was also positive. Ganciclovir was started based on the clinical features and the result of CMV serology. After 48 hours, there was a significant clinical improvement, with remission of fever, and he was discharged on the 13th day of hospitalization with oral valganciclovir, completing a 21-day antiviral course at home.

Conclusion

With this clinical case, the authors highlight the importance of considering CMV infection in evaluating patients with pneumonia, even in immunocompetent ones, particularly in those with no clinical improvement with antibiotics instituted for bacterial pneumonia, and when other causes have been ruled out.

Human cytomegalovirus pneumonia in an immunocompetent patient: a very uncommon but treatable condition

Human cytomegalovirus (CMV) is a double-stranded DNA virus that can cause widespread severe infection in immunocompromised individuals but is more typically a subclinical infection in immunocompetent individuals. Rarely, it can cause a serious infection in immunocompetent individuals. Here, we describe a 36-year-old otherwise healthy male who presented with fever, cough and malaise who was diagnosed with CMV pneumonia. He made a rapid recovery after initiation of ganciclovir and has been doing well on follow-up visits. We performed a comprehensive review of CMV pneumonia in immunocompetent individuals and have summarised the prior 16 reported cases of CMV pneumonia in immunocompetent patients. This article highlights the importance of considering CMV as a cause of pneumonia even in immunocompetent individuals, especially when the more common causes have been excluded. Early diagnosis allows prompt treatment and potentially complete recovery.

Cytomegalovirus (CMV) Pneumonitis: Cell Tropism, Inflammation, and Immunity

Human cytomegalovirus (HCMV) is an opportunistic pathogen causing disease mainly in immunocompromised patients or after congenital infection. HCMV infection of the respiratory tract leads to pneumonitis in the immunocompromised host, which is often associated with a bad clinical course. The related mouse cytomegalovirus (MCMV) likewise exhibits a distinct tropism for the lung and thus provides an elegant model to study host-pathogen interaction. Accordingly, fundamental features of cytomegalovirus (CMV) pneumonitis have been discovered in mice that correlate with clinical data obtained from humans. Recent studies have provided insight into MCMV cell tropism and localized inflammation after infection of the respiratory tract. Accordingly, the nodular inflammatory focus (NIF) has been identified as the anatomical correlate of immune control in lungs. Several hematopoietic cells involved in antiviral immunity reside in NIFs and their key effector molecules have been deciphered. Here, we review what has been learned from the mouse model with focus on the microanatomy of infection sites and antiviral immunity in MCMV pneumonitis.

Battle between Host Immune Cellular Responses and HCMV Immune Evasion

Human cytomegalovirus (HCMV) is ubiquitously prevalent. HCMV infection is typically asymptomatic and controlled by the immune system in healthy individuals, yet HCMV can be severely pathogenic for the fetus during pregnancy and in immunocompromised persons, such as transplant recipients or HIV infected patients. HCMV has co-evolved with the hosts, developed strategies to hide from immune effector cells and to successfully survive in the human organism. One strategy for evading or delaying the immune response is maintenance of the viral genome to establish the phase of latency. Furthermore, HCMV immune evasion involves the downregulation of human leukocyte antigens (HLA)-Ia molecules to hide infected cells from T-cell recognition. HCMV expresses several proteins that are described for downregulation of the HLA class I pathway via various mechanisms. Here, we review the wide range of immune evasion mechanisms of HCMV. Understanding the mechanisms of HCMV immune evasion will contribute to the development of new customized therapeutic strategies against the virus.

Challenges and Clinical Implications of the Diagnosis of Cytomegalovirus Lung Infection in Children

PURPOSE OF REVIEW

Pulmonary cytomegalovirus (CMV) infection is a potential lethal disease in children, but it remains a diagnostic challenge. The differentiation between latent CMV infections with viral shedding and active infections is difficult and may lead to false positives in bronchoalvolar lavage (BAL) PCR detection. This review summarizes current diagnostic approaches for CMV lung infection in children including progress in the identification of underlying immune defects linked to this condition.

RECENT FINDINGS

There is increasing literature supporting that the combined assessment of host risk factors and lung disease pattern is essential for the diagnosis of pulmonary CMV infection in children. The most important host risk factor is an immunecompromised state that has expanded from primary or acquired immunodeficiency (e.g., HIV) to include a myriad of immune-dysregulation syndromes (e.g., CTLA4, PIK3 defects). Newborns, paricularly those born premature, are also a high-risk group. At the pulmonary level, active CMV infection is typically characterized by alveolar compromise leading to hypoxemia, ground-glass opacities, and intra-alveolar infiltrates with CMV inclusions in lung biopsy. The identification of active CMV lung infection should trigger additional evaluation of immune defects (primary or secondary) impairing T and NK cell function or innate antiviral responses as well as other immune dysregulation disorders. Lung CMV infections in children are more prevalent in immunocompromised hosts and premature newborns. Lung CMV infections should prompt further investigation into conditions altering immune mechanisms usually in place to contain CMV infections. Common clinical and radiological patterns such as hypoxemia and ground-glass pulmonary opacities may allow early identification and treatment of CMV lung infection and underlying causes in the pediatric population.