Cytomegalovirus is frequently found in the bronchoalveolar lavage fluid of patients with HIV, but is thought seldom to be associated with significant morbidity and mortality. In those patients where CMV represents a true pathogen, pulmonary disease can result leading to respiratory failure. A clue to its existence as a true pulmonary pathogen may be facilitated by its finding in an extrapulmonary location and/or resolution with appropriate therapy.
A 34 year old male with AIDS, CD4 count 89 cells per cubic millimeter presented with abdominal pain, watery diarrhea, and a 30 lb weight loss over 1 month. He denied cough and shortness of breath. Oral temperature was 101, other vitals were unremarkable. Laboratory analysis showed only a mild anemia and hypoalbuminemia. Admission chest roentgenogram revealed a left pulmonary nodule. Respiratory isolation was instituted. Sputa collections were smear negative for AFB x 3. A chest CT uncovered the presence of multiple pulmonary nodules, the largest measured 2cm in diameter. Serum for Histoplama and Cryptococcal antigens were negative. Stool cultures confirmed the presence of C.difficile toxin and flagyl was instituted. There were no ova, parasites, fungi, or bacteria in the stool. Transthoracic needle aspirate of a left lower lobe nodule revealed cytopathic changes consistent with CMV, special stains negative for PCP, AFB, fungi and malignant cells. Colonoscopy with multiple biopsies confirmed the presence of CMV cytopathic changes, cryptitis, ulceration, edema, and hemorrhage. The patient was started on IV gancyclovir. The diarrhea resolved and the follow up chest CT 5 weeks later showed a decrease in the size of the largest pulmonary nodules and resolution of the smaller ones. The patient will continue on oral gancyclovir until the CD4 count remains in the range of 100-150 cells per cubic millimeter for 6 months.
CMV is a beta-herpes virus. The risk of exposure increases with age and is found in 50–70% of adults and 100% of homosexuals. It is acquired transplacentally, through an infected birth canal, exposure to infected body secretions, blood transfusions, and organ transplants. Overwhelming infection resulting from reactivation of latent CMV can occur in those who become immunocompromised, as in HIV or in those treated with chemotherapy or prolonged courses of corticosteroids. Infection results in retinitis, gastroenteritis, and pneumonitis. Rarely, CMV can cause necrotizing bronchiolitis, diffuse alveolar hemorrhage, pulmonary vasculitis, and necrotizing tracheitis leading to upper airway obstruction. The most common radiologic findings are ground glass opacities and consolidation. Less commonly found are interstitial opacities, discrete nodules or masses, and miliary nodules. Histopathologically, nuclear and cytoplasmic inclusions are seen in cells with evidence of inflammation of the involved tissue. Without evidence of inflammation, the findings may not represent a true pulmonary pathogen and search for another pathogen should continue.
The diagnosis of CMV requires culture or identification of characteristic cytopathologic inclusions in infected cells and an inflammatory reaction in biopsy specimens. The decision to treat in this case was facilitated by CMV cytopathic changes and extensive inflammation in the colon biopsy specimens. The improvement of the multiple pulmonary nodules with therapy for CMV colitis further supported the diagnosis of CMV pulmonary disease.
E.U. Bollenbacher, None.