Thrombose portale au cours d'une hépatite aiguë de primo-infection à cytomégalovirus de l'immunocompétent

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.

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.

Risk factors of venous thrombo-embolism during cytomegalovirus infection in immunocompetent individuals. A systematic review

Most of the effects and complications of cytomegalovirus (CMV) infection are still unknown, even though its tropism for the endothelium has been extensively investigated. In fact, CMV is suspected to be a cause of venous thrombo-embolism (VTE) since 1974, but there is still no consensus about the management of CMV-related thrombosis and how to prevent it. Cytomegalovirus-related thrombosis has been reported mostly in immunocompromised patients, rarely in immunocompetent individuals. In order to identify potential risk factors of CMV-related thrombosis, we performed a systematic review of the literature regarding immunocompetent patients with cytomegalovirus infection and thrombosis. We found 115 cases with a mean age of 37.36 years (SD ± 16.43 years). Almost half the female patients were assuming EP contraception at the time of the event, and almost half the patients were affected by a coagulation disorder. Interestingly, just two women and four men had no risk factor for thrombosis other than the CMV infection at the time of the event. In conclusion, coagulation disorders and EP contraception have to be taken into a great deal of consideration in patients with CMV infection, since they could be important risk factors for VTE. Knowing the correlation with coagulation disorders, the use of anticoagulation drugs cannot be considered overtreatment. It was not feasible to determine the usefulness of an antiviral treatment. Further studies, even randomized ones, are required to determine the usefulness of antiviral drugs and the real prevalence of CMV-related VTE.

Thrombosis associated with acute cytomegalovirus infection: a meta-analysis

BACKGROUND

Thrombosis associated with acute cytomegalovirus (CMV) infection has been reported in the medical literature almost 100 times thus far. Still, the clinical characteristics of patients with both conditions have never been systematically reviewed and described.

METHODS

A literature search was conducted for all (n=97) reports concerning thrombosis associated with acute CMV infection. The current knowledge concerning this unique association and previous clinical experience are presented here.

RESULTS

The incidence of thrombosis among acute CMV infection hospitalized patients was 6.4%, and the incidence of acute CMV infection among thrombosis hospitalized patients was 1.9-9.1%. Most (n=64; 65.9%) reported patients were immunocompetent. Mean age of reported patients was 39.7 ± 14.9 years. Female-male ratio was 1:1. DVT/PE, splanchnic vein thrombosis and splenic infarction were the most prevalent thromboses associated with acute CMV infection. While DVT/PE was more prevalent among immunocompromised patients, splanchnic vein thrombosis was more prevalent among immunocompetent patients. Inherited predispositions for thrombosis were significantly more prevalent among immunocompetent patients. Immunocompromised patients were treated with antiviral agents significantly more often. Duration of anticoagulation therapy varied significantly between reported patients. In-hospital mortality rates were 4.9-22.2%.

CONCLUSIONS

We believe physicians should be alert for symptoms and signs of thrombosis in patients with acute CMV infection, and for symptoms and signs of acute CMV infection in patients with thrombosis.

Inherited and acquired predispositions for thrombosis in immunocompetent patients with cytomegalovirus-associated thrombosis

BACKGROUND

Thrombosis is a rare complication of cytomegalovirus (CMV) infection in immunocompetent patients. The clinical circumstances of this complication have never been studied, to the best of our knowledge.

AIM

We reviewed all reports on CMV-associated thrombosis in immunocompetent adults found in the literature, in search for thrombosis risk factors other than CMV.

METHODS

Our search yielded 32 case reports and case series on CMV-associated thrombosis in immunocompetent adults. Reports on immunocompromised patients, infants and elderly patients were excluded. All reports were reviewed for other, acquired as well as inherited, predispositions for thrombosis.

RESULTS

Reports on 39 immunocompetent adults were reviewed, mean age for which was 34.9+/-10.8years. Overall, 14 (35.9%) patients had one or more acquired predispositions for thrombosis; 16 (45.7%) of the 35 patients that were investigated for inherited thrombophilias had one or more inherited predispositions for thrombosis. Only 12 (34.3%) patients were found to have no acquired or inherited predispositions for thrombosis other than CMV. The most common (n=13; 33.3%) acquired predisposition for thrombosis was daily use of oral contraceptives. The most common (n=6; 17.1%) inherited predisposition for thrombosis was factor V Leiden mutation.

CONCLUSIONS

Most immunocompetent adults with CMV-associated thrombosis have other acquired or inherited predispositions for thrombosis. Hence, addressing these predispositions in patients with CMV-associated thrombosis may be of great clinical importance.