SESSION TITLE: Infectious Disease Cases I
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM
INTRODUCTION: Cytomegalovirus (CMV) is widely latent in healthy patients but is rarely considered as a source of infection in the immunocompetent. We report an immunocompetent patient with diffuse alveolar damage that was proven on biopsy to be CMV pneumonitis and successfully treated prior to cardiac transplantation.
CASE PRESENTATION: A 53 year old male suffered a catastrophic myocardial infarction with cardiogenic shock. Coronary artery bypass was unsuccessful and he was listed for heart transplantation. A pre-transplant workup was negative for immunocompromise. Two weeks into his ICU course, he developed hypoxemia accompanied by diffuse pulmonary infiltrates on imaging. Bronchoalveolar lavage revealed no blood or organisms. Solumedrol was initiated but his hypoxemia worsened and he required mechanical ventilation. Histology on open lung biopsy showed diffuse alveolar damage. No organisms were seen, but subsequent staining revealed widespread CMV inclusion bodies with a quantitative serum CMV PCR of 38,400 copies/mL. Despite treatment with gancyclovir and CMV human immune globulin, CMV titers remained positive. Leflunomide, an immunomodulator with anti-CMV activity, was added with clearance of his CMV viremia. His pneumonitis resolved and he underwent successful heart transplant. Leflunomide was maintained as part of his post-transplant regimen with sustained negative CMV titers.
DISCUSSION: While CMV seropositivity in healthy subjects is common, CMV pneumonitis has been historically associated with immunocompromise. It frequently complicates solid organ transplantation. CMV viremia in the critically ill appears more common than previously recognized (1) with clinical consequences (1,2). Recognized CMV pneumonitis in the immunocompetent patient is rare. Successful organ transplantation soon after the treatment of severe CMV pneumonitis has not been previously reported. Successful identification and treatment of CMV pneumonitis may be complicated by its rarity. Treatment with conventional therapy may prove inadequate. Leflunomide possesses unique antiviral properties that make it a useful adjunct in refractory CMV infection. It may also be used to immunosuppress in a post-transplant regimen (3).
CONCLUSIONS: Many instances of pneumonitis remain idiopathic despite extensive conventional workup. CMV is often not included in the workup due to its perceived rarity in the immunocompetent. As a potentially life threatening and treatable infection, aggressive workup for CMV infection should be considered in the critically ill patient with unexplained and acute pneumonitis.
Reference #1: Limaye AP et al. Cytomegalovirus reactivation in critically ill immunocompetent patients. JAMA.2008;300(4):413-422.
Reference #2: Heininger A et al. Cytomegalovirus reactivation and associated outcome of critically ill patients with severe sepsis. Crit Care. 2011;15(2):R77.
Reference #3: B. Chacko, G.T. John. Leflunomide for cytomegalovirus: bench to bedside. Transpl Infect Dis 2012. 14: 111-120.
DISCLOSURE: The following authors have nothing to disclose: Nalin Mallik, Luke White, Sivagini Ganesh
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