Cytomegalovirus mononucleosis with jaundice as presenting sign

Cytomegalovirus Hepatitis in Immunocompetent and Immunocompromised Hosts

Human cytomegalovirus (HCMV) infection is common and affects between 40-100% of the worldwide population. However, the majority of cases are asymptomatic and when severe disease occurs, it is usually restricted to immunocompromised patients. Liver involvement by HCMV differs significantly, accordingly to the immune status of the host. In immunocompromised patients, particularly liver transplant patients, it often causes clinically significant hepatitis. On the other hand, in immunocompetent patients, HCMV hepatitis requiring hospitalization is extremely rare. This review aims to appraise studies regarding the pathophysiology of HCMV hepatitis, including mechanisms of latency and reactivation and its contribution to disease development, clinical presentation, diagnostic modalities and treatment, with a focus on comparing different aspects between immunocompromised and immunocompetent hosts.

Cytomegalovirus Hepatitis in an Immunocompetent Patient: A Cause of Fever of Unknown Origin

Acute hepatitis is most often self-resolving and a benign condition that rarely requires any anti-viral drugs. In immunocompromised patients (HIV-infected patients and transplant recipients), the morbidity and mortality associated with cytomegalovirus (CMV) infection have been extensively reported in the medical literature. We are describing a rare case of acute severe cytomegalovirus hepatitis in an immunocompetent host. In immunocompetent individuals, in most cases, it causes a subclinical infection and hence doesn't require an anti-viral agent for treatment. Our patient was unique because it presented with clinically severe hepatitis and was uncharacteristically treated with the use of antiviral medications.

Cytomegalovirus-induced hepatitis in an immunocompetent patient

Patient: Female, 20

Final Diagnosis: Cytomegalovirus-induced hepatitis

Symptoms: Chills • cough dry • decreased appetite • fever

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Antiviral T cell response triggers cytomegalovirus hepatitis in mice

One common sign of human cytomegalovirus infection is altered liver function. Murine cytomegalovirus strain v70 induces a rapid and severe hepatitis in immunocompetent mice that requires the presence of T cells in order to develop. v70 exhibits approximately 10-fold-greater virulence than the commonly used strain K181, resulting in a more severe, sustained, and lethal hepatitis but not dramatically higher viral replication levels. Hepatitis and death are markedly delayed in immunodeficient SCID compared to immunocompetent BALB/c mice. Transfer of BALB/c splenocytes to SCID mice conferred rapid disease following infection, and depletion of either CD4 or CD8 T cells in BALB/c mice reduced virus-induced hepatitis. The frequency of CD8 T cells producing gamma interferon and tumor necrosis factor in response to viral antigen was higher in settings where more severe disease occurred. Thus, virus-specific effector CD8 T cells appear to contribute to lethal virus-induced hepatitis, contrasting their protective role during sublethal infection. This study reveals how protection and disease during cytomegalovirus infection depend on viral strain and dose, as well as the quality of the T cell response.

Cytomegalovirus infection-associated fulminant hepatitis in an immunocompetent adult requiring emergency living-donor liver transplantation: report of a case

Human cytomegalovirus (CMV) infection is usually self-limiting in healthy adults, but it can lead to significant complications. This report presents the case of an immunocompetent adult with fulminant hepatitis caused by a CMV infection requiring emergency living-donor liver transplantation. A 39-year-old female with persistent fever for 6 weeks was referred for fulminant hepatitis, but the underlying etiology was not identified. Rapid deterioration of consciousness led to an emergency living-donor liver transplant using a modified right lobe graft. She showed increasing CMV antigenemia after surgery and the explant liver pathology showed massive hepatic necrosis with positive staining for CMV protein. Treatment with ganciclovir improved the graft liver function and her general condition recovered. This report presents a rare case of CMV-associated fulminant hepatitis which led to emergency liver transplantation. Although CMV is rare, it should be included in the differential diagnosis of patients with severe hepatitis, even immunocompetent patients, after other more common etiologies have been excluded.

The history of cytomegalovirus and its diseases

Intranuclear inclusions typical of cytomegalovirus infections were first noticed in 1881 by German scientists who thought they represented protozoa. After viruses were grown in cell cultures, Weller, Smith and Rowe independently isolated and grew CMV from man and mice in 1956-1957. Antibodies in 30-100% of normal adults indicate not only a past infection, but the presence of a present latent infection. The presence of CMV DNA in tissues and most organs surveyed indicates the ubiquity of latent infection. CMV disease requires the virus and some deficiency of immunity such as occurs in the immature fetus, in AIDS, and in transplant patients on immunosuppressive drugs. Antiviral agents can inhibit CMV replication but they cannot prevent or cure latent infections. A pharmacological approach using the many leads in understanding latency is needed.

CMV and blood transfusions

Among the human herpesviruses, cytomegalovirus (CMV) is the only one that has assumed significant importance in blood transfusion. Transfusion transmission of CMV (TT-CMV) to seronegative immunocompromised patients can lead to lethal CMV disease. Studies over the past 30 years have demonstrated that monocytes latently infected with CMV represent the primary vector for TT-CMV, and that TT-CMV can be largely abrogated by transfusing at-risk patients with either seronegative units or blood filtered to remove white blood cells. However, the small number of cases of breakthrough TT-CMV that follow transfusion of either seronegative or filtered blood still produce morbidity and mortality. These circumstances have motivated ongoing efforts to provide improved protection from TT-CMV, including the use of CMV DNA amplification for blood screening, and pathogen inactivation to sterilise all blood components prior to transfusion.

Herpesvirus infection of the liver

The human herpesviruses can produce a wide variety of disease in the liver (Table 7). The immunocompromised host is particularly susceptible to hepatic manifestations of herpesvirus disease. CMV is the most common opportunistic pathogen in the immunocompromised patient. The clinical presentation of hepatic herpesvirus infection is often nonspecific. A high index of suspicion and rapid progression to liver biopsy to document viral replication (alpha- and betaherpesviruses) or outgrowth of virus-infected cells (gammaherpesviruses) can lead to lifesaving therapeutic interventions.

Viral hepatitis. The alphabet game

Differential diagnosis of viral hepatitis begins with a check for darkened urine and bile in the urine. These hallmarks of conjugated hyperbilirubinemia immediately rule out prehepatic liver disease. Next, studies are done for the elevated transaminase levels that are characteristic of hepatitis infection, and a thorough history is taken to rule out drug- and toxin-induced hepatitis that may mimic acute viral hepatitis. Elevated alkaline phosphatase is a good marker of cholestasis. Ultrasonography can clarify this diagnosis. The classic presenting symptoms of viral hepatitis are jaundice, nausea, vomiting, malaise, anorexia, and dull right upper quadrant pain. However, serologic studies are needed to detect the presence of specific viral agents.

The status of CMV as a human pathogen

Cytomegalovirus (CMV) is a common infectious agent which is well adapted to its host. Following primary infection, which is almost always asymptomatic in people with normal immunity, the virus establishes latency at sites which are unknown. The virus is probably maintained in this latent state by immune surveillance mechanisms since immunosuppression frequently leads to reactivation of virus.

Cytomegalovirus has been identified in most anatomical areas of the human body. The aim of this article is to define criteria for pathogenicity so that clinical and experimental data can be reviewed to determine if CMV is likely to cause disease at these various clinical sites. Thus, patients have been shown to die frequentlywithCMV but do they diefromit?

Quantitative and qualitative detection of cytomegalovirus-specific antibodies using two types of enzyme-linked immunosorbent assay

An indirect ELISA and an inhibition ELISA were developed for the detection of cytomegalovirus (CMV)-specific immunoglobulin G (IgG) and CMV-specific total immunoglobulin, respectively. Both assays were more specific than the complement fixation (CF) test, and titres of positive sera were 660 times higher by IgG ELISA and 6 times higher by inhibition ELISA than titres by the CF test. Titres by IgG ELISA were reliably determined using the absorbance obtained at a single serum dilution of 1/1,000 in conjunction with a standard graph. Both ELISAs compared favourably with each other in sensitivity and specificity in determining CMV immune status. The inhibition ELISA, in particular, provides a simple and reliable method of screening sera, which requires no control antigen or predilution of sera. It should prove useful for large-scale screening procedures, such as blood donor testing.

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 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.

Demonstration of IgG EA (early antigen) and IgM MA (membrane antigen) antibodies in CMV infection of healthy infants and in those with liver disease

The sequence of antibody production to various virus-specific antigens in CMV infection in infancy was studied. In healthy infants, IgG EA antibody was demonstrated in 18% of cord sera, and disappeared within two months after birth in all cases not shedding virus. The nonmaternal EA antibody was produced following virus excretion and decreased rapidly following cessation of virus excretion. Thus, demonstration of EA antibody in infants after 2 months of age was found to indicate acquired CMV infection, even when CMV could not be isolated. IgM MA antibody did not persist as long as EA antibody, disappearing before cessation of virus excretion. Both IgG EA and IgM MA antibodies were more frequently demonstrated in infants with hepatitis than in healthy infants. These findings suggest the possible association of CMV with hepatitis in infants.

Herpesviruses

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Cytomegalovirus infection and the Guillain-Barré syndrome

A fatal case is described of the Guillain-Barré syndrome due to cytomegalovirus infection, which was associated with hepatitis, myocarditis and viral pneumonia. Previous cases, which have usually run a benign course, are reviewed. Attention is drawn to the possible adverse effect of steroid therapy.

Liver disease in renal transplant recipients

Liver disease is a common complication in renal transplant recipients. Several types of liver disease can occur. The most common are acute and chronic hepatitis. The variety of acute hepatitis include hepatitis A, hepatitis B, cytomegalovirus hepatitis, herpes simplex hepatitis and azathioprine hepatitis. The incidence of azathioprine hepatitis may not be as high as initially suggested. Chronic hepatitis is a serious problem because the disease seems to be progressive despite prednisone therapy. The causes of this chronic hepatitis are not fully known, although hepatitis B, cytomegalovirus and herpes simplex virus have been implicated. Discontinuation of azathioprine therapy has no appreciable effect on the course of chronic hepatitis.

Acute encephalopathy with liver dysfunction, chylous ascites and cytomegalovirus infection

A child with acute encephalopathy and liver dysfunction subsequently developed acute chylous ascites. Titers for cytomegalovirus increased from less than 1:2 to 1:32 during the illness, and cytomegalovirus was isolated from the urine. The case is the first one possibly linking cytomegalovirus and acute encephalopathy and liver dysfunction in a child. In our patient, enlargement of the abdominal lymph nodes, as seen on a lymphangiogram, resulted in a severe obstruction of abdominal lymphatic flow, producing a transudation of lymph into the peritoneal cavity. The acute chylous ascites associated with mesenteric lymphadenitis was likely caused by the cytomegalovirus infection.

Cytomegalovirus mononucleosis in a healthy adult: association with hepatitis, secondary Epstein-Barr Virus antibody response and immunosuppression

A 35 year old previously healthy physician had clinical manifestations of a mononucleosis illness complicated by arthralgia, vesicular pharyngitis and hepatitis. Initially, the patient had cytomegalovirus (CMV) viremia (predominantly in polymorphonuclear leukocytes) followed by the presence of CMV in the urine, throat and semen. He also had an antibody response to the Epstein-Barr virus which appeared to be a secondary type. During the acute phase of illness, only 7 per cent of the patient's lymphocytes formed spontaneous T cell rosettes as compared to a normal value of 65 to 70 per cent. Concurrently, evidence of abnormal delayed hypersensitivity was manifested by the loss of reactivity to mumps skin test antigen. All clinical and laboratory abnormalities except for the persistence of CMV in the pharynx, urine and semen returned to normal after resolution of the clinical illness.

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 myocarditis

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Syndromes of infectious mononucleosis

Physicians are becoming more aware of the existence and diversity of the infec tious-mononucleosislike responses which patients may develop in certain circum stances. Differentiation and identification call for knowledgable familiarity with these various clinical-hematologic responses.

Liver transplantation in man. The significance, patterns, and control of infection

Of 9 patients who survived the immediate postoperative period after hepatic transplantation, 6 later died from infection. Pulmonary infection was the major problem. Biliary infection related to bile fistulas may be less in the future with the improved technique of a cholecystdochostomy which was carried out in the last 2 patients. Frequent bacteriaemias were noted and the organisms were often the same as those found in the bile. Most infections were thought to be autogenous. Cytomegalovirus infection occurred in 6 patients, but in none was there evidence that the virus did harm. Broad-spectrum antibiotic therapy was freely used in the earlier patients but was often followed by superinfection with resistant organisms and fungi. The present policy is not only to use antibiotics sparingly but to rely on narrow-spectrum drugs wherever possible.

Latent cytomegalovirus infection in blood donors

Twenty-one out of 32 apparently healthy blood donors aged 21 to 65 years yielded positive complement fixation tests with a cytomegalovirus antigen, at titres ranging from 1:8 to 1:64. Virus was present in leucocyte cultures of fresh peripheral blood of two seropositive subjects from a total of 35 donors examined. Plasma and 48-hour stored blood specimens failed to disclose virus in culture. Viruria could not be demonstrated, and there was no evidence of recent illness in the study group. These findings suggest that subclinical viraemia is not uncommon in blood donors.

Cytomegalic inclusion-body disease associated with acquired autoimmune haemolytic anaemia

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Cytomegalic inclusion disease in the adult

The distribution of infected cells in 13 necropsies on adults with cytomegalovirus disease is reported and discussed in relation to the local damage caused by the infection and predisposing factors. The distribution, with lung as the most common site, but other organs such as thyroid, liver, and colon not infrequently involved, agrees fairly well with other series. No heavy infection confined to one organ was found, and it is concluded that a truly localized infection in the adult probably does not occur. Evidence of destructive inflammatory changes attributable to the virus was scanty; a lymphocyte and plasma cell infiltrate was sometimes found, and microglial nodules were found in a case with inclusions in the brain. In one case heavy cytomegalovirus infection in the colon was associated with, and probably caused, marked colonic ulceration which led to the death of the patient. THE MAJOR PREDISPOSING FACTOR TO INFECTION IN THIS SERIES WAS CORTICOSTEROID THERAPY: eight of the 13 patients had been treated with steroids and one had Cushing's syndrome associated with a bronchial carcinoma. Three of the other four patients had a very few inclusions only. Adrenal involvement was not found in any of the steroid-treated patients but was present in two of the four patients not treated with steroids where adrenal sections were available. It is concluded that most adult patients with cytomegalovirus infection have impaired immune mechanisms, and that heavy infection may rarely lead to a clinically serious disease.