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Cytomegalovirus Pneumonia

Pneumonia in Cytomegalic Inclusion Disease

Cytomegalovirus pneumonia is an inflammation of the lung tissue caused by primary or secondary infection by the cytomegalovirus, which belongs to the Herpesviridae group of viruses. It mostly affects immunocompromised individuals.


Presentation

Cytomegalovirus (CMV) pneumonia can occur regardless of host immune status, however, the infection is latent in immunocompetent individuals. Reactivation of the virus is possible, and this leads to secondary infection.

In the context of a normally functioning immune system, infection is largely asymptomatic and full blown pneumonia is rare, even if infiltrates are visible radiologically. Fever, lymphadenopathy and flu-like symptoms, in what is termed CMV mononucleosis, with or without the presence of a cough, is the most frequently described clinical presentation. In the event that severe pneumonia is contracted, full recovery following initiation of antiviral treatment is typical.

In practice, most documented cases of cytomegalovirus pneumonia are confined to immunosuppressed individuals, and the disease is often severe and fatal. This includes those who have undergone chemotherapy, radiotherapy, long-term steroid therapy, organ and bone marrow transplant recipients and those suffering from acquired immunodeficiency syndrome (AIDS). The latter are at the highest risk when serum concentrations of T helper cells fall below 50 cells per cubic millimeter. Among those who receive organ transplants, the probability of CMV pneumonia differs; for instance those who receive cells or organs originating from another donor have up to a 30% risk, whereas those receiving their own harvested cells have a much lower risk (1%- 6%) [1]. Furthermore, bone marrow transplant recipients are the most susceptible to disease, with untreated case fatality rates of over 80%, and 15-75% with appropriate treatment [1]. Symptoms experienced include

Symptoms of CMV pneumonia include cough, fever, night sweats, respiratory distress, hypoxia, myalgia, arthralgia, and fatigue. Radiological evidence of disease can sometimes precede outward signs of infection. The infection may affect other organ systems simultaneously, thus provoking a wider symptom profile. As it is a life-threatening illness, immunosuppressed patients are habitually initiated on CMV prophylaxis [2] [3] [4].

Importantly, neonates can also suffer from cytomegalovirus pneumonia when they acquire the infection from infected mothers through the placenta, birth canal, or during and breastfeeding.

Fever
  • Fever and dyspnea were the most frequent symptoms. The most frequent radiological signs were bilateral pulmonary infiltrates. Six cases were complicated by hemophagocytic lymphohistiocytosis.[ncbi.nlm.nih.gov]
  • Fever, lymphadenopathy and flu-like symptoms, in what is termed CMV mononucleosis, with or without the presence of a cough, is the most frequently described clinical presentation.[symptoma.com]
  • An abnormal 111In-white blood cell scan led to the discovery of a pulmonary source of his recurrent fevers.[ncbi.nlm.nih.gov]
  • A 24-year-old male was admitted to the hospital with complaints of cough, fever and dyspnoea. He was receiving immunosuppressive therapy for polyarteritis nodosa.[ncbi.nlm.nih.gov]
  • Abstract A 38 year-old woman, who was previously fit and well, presented with a 10 day history of fever and non-specific symptoms. Initial chest X-ray demonstrated patchy nodular infiltrates bilaterally. She became increasingly hypoxaemic.[ncbi.nlm.nih.gov]
Malaise
  • Examination reveals crackles in the lungs and low oxygenation Loss of appetite, discomfort, general malaise or tiredness Muscular ache, fatigue, excessive sweating (at nights) Coughing blood with severe pneumonia Co-existing infections in the lung, such[dovemed.com]
  • Symptoms Cough Fatigue Fever General discomfort, uneasiness, or ill feeling (malaise) Loss of appetite Muscle aches or joint pains Shortness of breath Shortness of breath on exertion Sweating, excessive (night sweats) Low oxygen levels in the blood (hypoxemia[dxline.info]
  • In immunocompetent patients 90%: asymptomatic course 10% : CMV mononucleosis Fever, malaise, myalgia / arthralgia, fatigue, headache Less common: sore throat, cervical lymphadenopathy, hepatomegaly, splenomegaly Differential diagnosis: infectious mononucleosis[amboss.com]
  • Symptoms may include: Cough Fatigue Fever General discomfort, uneasiness, or ill feeling ( malaise ) Loss of appetite Muscle aches or joint pains Shortness of breath Sweating, excessive (night sweats) The goal of treatment is to use antiviral drugs to[medlineplus.gov]
Chills
  • She had fevers, chills, a red rash, muscle pain, and joint pains. She works in a daycare center, and some of her colleagues had similar symptoms. This resolved in 1 week. Today, there are no significant findings on physical exam.[medbullets.com]
  • If you are a healthy adult, call your doctor if you have severe abdominal pain, vomiting or fevers that last longer than 48 hours or if you have significant fatigue, sweats, chills or are losing weight.[drugs.com]
  • He reports that he has had difficulty swallowing, had fevers and chills, nausea, vomiting, and belly pain. He reports that he has been compliant with his HIV medications. On physical exam, he has ulcers in his oropharynx.[medbullets.com]
  • In some people, the virus causes mild symptoms that mimic the flu or infectious mononucleosis, such as fever, chills, body aches, headache, swollen lymph nodes *, sore throat, and fatigue.[humanillnesses.com]
Turkish
  • Abstract A case of hypertrophic osteoarthropathy is reported in a 3-year-old Turkish girl. She had combined immunodeficiency, later shown to be the bare lymphocyte syndrome, and chronic pneumonia. Lung biopsy showed cytomegalovirus.[ncbi.nlm.nih.gov]
Cough
  • Fever, lymphadenopathy and flu-like symptoms, in what is termed CMV mononucleosis, with or without the presence of a cough, is the most frequently described clinical presentation.[symptoma.com]
  • A 24-year-old male was admitted to the hospital with complaints of cough, fever and dyspnoea. He was receiving immunosuppressive therapy for polyarteritis nodosa.[ncbi.nlm.nih.gov]
  • A 30-year-old male was diagnosed with T-cell lymphoma after persistent cough and lymphadenopathy. Fever, abdominal pain, diarrhea, rash, and dyspnea occurred after HSCT.[ncbi.nlm.nih.gov]
  • The clinical presentations of these patients were nonspecific, including fever (100% of patients), shortness of breath (71%), cough (76%), and Pao2 of 75 mm Hg (88%).[ncbi.nlm.nih.gov]
  • Hypoxia, if extreme, may be fatal. cytomegalovirus pneumonia Pulmonology A viral pneumonia characterized by fever, non-productive cough, SOB and association with PCP, especially in AIDS; hypoxia, if extreme, may be fatal.[medical-dictionary.thefreedictionary.com]
Dyspnea
  • Fever and dyspnea were the most frequent symptoms. The most frequent radiological signs were bilateral pulmonary infiltrates. Six cases were complicated by hemophagocytic lymphohistiocytosis.[ncbi.nlm.nih.gov]
  • Fever, abdominal pain, diarrhea, rash, and dyspnea occurred after HSCT. The young man developed severe CMV infection with CMV detected in the bronchoalveolar lavage fluid and gastrointestinal tract.[ncbi.nlm.nih.gov]
  • All patients of CMV pneumonia had dyspnea, 90% had fever and 71% had cough.[erj.ersjournals.com]
  • A 29 year-old female with a history of systemic lupus erythematosus presented with a seven-day history of fever, dyspnea and a non-productive cough.[swjpcc.com]
  • ., following bone marrow transplant or in HIV / AIDS patients with CD4 50 cells/mm 3 ) Clinical findings: fever, nonproductive cough, dyspnea Diagnostics: Chest x-ray : diffuse bilateral interstitial infiltrates Detection of CMV in bronchoalveolar lavage[amboss.com]
Dry Cough
  • The signs and symptoms of CMV Pneumonia are: Fever, dry cough, and shortness of breath, are the most common symptoms.[dovemed.com]
  • cough If you're HIV-positive, your chance of becoming sick with CMV is greatest when your CD4 count is below 100.[webmd.com]
Tachypnea
  • CONCLUSIONS: CMV pneumonia should always be suspected in IBD patients who present with fever and tachypnea, especially if the latter is worsening and/or is associated with dyspnea. Treatment must be early and specific.[ncbi.nlm.nih.gov]
  • Conclusion We report an acute CMV infection case, which presented with fever, cough, sputum and tachypnea. The latter deteriorated rapidly and is associated with respiratory failure.[aclr.com.es]

Workup

The diagnosis of CMV pneumonia combines both clinical observation and medical imaging. Chest X-ray and computerized tomography (CT) scan are the relevant imaging techniques. They may show ground glass or patchy opacities across both lung fields [5] [6]. Despite this, possible X-ray and CT findings are variable.

Laboratory tests involve collecting tissue samples from the blood, urine or alveoli through bronchoalveolar lavage. These samples are used for serology through the means of immunological assays, viral culture, and DNA polymerase chain reaction (PCR). Caution should be exercised when interpreting results, as they can be misleading. Histopathologic diagnosis, for which a lung biopsy is needed, is more accurate but may prove hazardous for bedridden patients [7].

Pulmonary Infiltrate
  • A 61-year-old woman who had undergone an operation for thymoma 17 years previously suddenly became dyspneic and showed bilateral pulmonary infiltrates on a chest radiograph.[ncbi.nlm.nih.gov]
  • The most frequent radiological signs were bilateral pulmonary infiltrates. Six cases were complicated by hemophagocytic lymphohistiocytosis. Eight of the 13 were transferred to intensive care units and four of them died.[ncbi.nlm.nih.gov]
  • There are few studies reported the correlation of clinical, and pulmonary infiltration with histopathological evidence of CMV pneumonia.[erj.ersjournals.com]
  • infiltrate and organ dysfunction.[journals.lww.com]
  • The only morbidity occurred in two patients who had fever and a pulmonary infiltrate in the lung segments subjected to lavage within 24 hours after the procedure.[nejm.org]
Bilateral Pulmonary Infiltrate
  • A 61-year-old woman who had undergone an operation for thymoma 17 years previously suddenly became dyspneic and showed bilateral pulmonary infiltrates on a chest radiograph.[ncbi.nlm.nih.gov]
  • The most frequent radiological signs were bilateral pulmonary infiltrates. Six cases were complicated by hemophagocytic lymphohistiocytosis. Eight of the 13 were transferred to intensive care units and four of them died.[ncbi.nlm.nih.gov]
Bilateral Pulmonary Infiltrate
  • A 61-year-old woman who had undergone an operation for thymoma 17 years previously suddenly became dyspneic and showed bilateral pulmonary infiltrates on a chest radiograph.[ncbi.nlm.nih.gov]
  • The most frequent radiological signs were bilateral pulmonary infiltrates. Six cases were complicated by hemophagocytic lymphohistiocytosis. Eight of the 13 were transferred to intensive care units and four of them died.[ncbi.nlm.nih.gov]
Ground Glass Appearance
  • A high-resolution CT thorax showed diffuse multilobular ground glass appearance with peripheral nodular shadowing, consistent with a viral pneumonia. CMV IgM antibody was positive and CMV PCR was positive on two subsequent occasions.[ncbi.nlm.nih.gov]
Cavitary Lesion
  • Following CMV pneumonia, cavitary lesions again occurred in the patient's lungs that were thought to be the first case of cavitary lesions caused by Nocardia asiatica infection.[ncbi.nlm.nih.gov]
Treponema Pallidum
  • Systemic infection in the mother, such as Rubella, CMV, Treponema pallidum, Listeria monocytogenes, tuberculosis, and human immunodeficiency virus may cause intrauterine pneumonia.[ijpmonline.org]
Viral Inclusion Body
  • Some of the alveolar spaces were lined by large cells containing homogenous dark purple viral inclusion bodies, surrounded by a characteristic halo, suggestive of CMV infection [Figure 3].[ijpmonline.org]
  • The pathologic hallmark of CMV infection is an enlarged cell with viral inclusion bodies. Cells that exhibit cytomegaly are also seen in infections caused by other Betaherpesvirinae.[emedicine.medscape.com]

Treatment

  • Antiviral treatment with ganciclovir or foscarnet was associated with improved outcome compared with no antiviral treatment.[ncbi.nlm.nih.gov]
  • Early diagnosis, active treatment, and rational reduction of immunosuppressants are crucial for successful kidney transplantation.[ncbi.nlm.nih.gov]
  • Individualized immunomodulatory therapy is essential to the treatment of CMV pneumonia after LT.[ncbi.nlm.nih.gov]
  • Prompt recognition and treatment of infection is imperative for successful transplantation.[ncbi.nlm.nih.gov]
  • Abstract Cytomegalovirus (CMV) often persists in the lungs of marrow transplant patients with CMV pneumonia, despite ganciclovir (GCV) treatment.[ncbi.nlm.nih.gov]

Prognosis

  • Prognosis was poor in patients who were ventilator-dependent at initiation of therapy (median survival 17 days), with only 1 long-term survivor.[ncbi.nlm.nih.gov]
  • Incidence and prognosis of CMV disease in HIV-infected patients before and after introduction of combination antiretroviral therapy. Infection. 2005;33:345–9. PubMed CrossRef Google Scholar 6.[link.springer.com]
  • In such cases, the mortality approaches 90%, if the patients are not treated with these drugs The need for mechanical ventilation is a sign of poor prognosis Additional and Relevant Useful Information for Cytomegalovirus Pneumonia: Some home care tips[dovemed.com]
  • However, screening for congenital CMV infection is not currently recommended in the UK. [ 13 ] Prognosis The prognosis of patients with CMV hepatitis is generally good. Most patients recover completely.[patient.info]

Etiology

  • Potential viral etiologies should therefore be considered in cancer patients with pneumonia receiving non-transplantation chemotherapy-regimens, particularly if steroids are a component of their therapy.[ncbi.nlm.nih.gov]
  • However, no significant differences were observed in BAL cellular characteristics between patients with and without pneumonia nor between patients with CMV or other etiologies of pneumonia.[ncbi.nlm.nih.gov]
  • There was no correlation of the presence of either cytokine with cytomegalovirus pneumonia, pneumonia of other etiology or absence of pneumonia.[ncbi.nlm.nih.gov]
  • Pneumonia is inflammation of the lung, which includes infectious and non-infectious etiologies. It is a subset of the medical lung diseases. This article primarily deals with the infectious pneumonias.[librepathology.org]
  • (Etiology) Cytomegalovirus Pneumonia is a viral infectious disease which occurs in patients with poor immune system, and sometimes in healthy people as well.[dovemed.com]

Epidemiology

  • Editors Charles Dela Cruz and Richard Wunderlink have assembled an expert team of authors on topics such as: Epidemiology of Viral Pneumonia; Diagnostic Testing for Viral and Atypical Infections;Lung Microbiome: Atypical Infections and Viruses; RSV Pneumonia[books.google.com]
  • Beam E, Razonable RR(2012) Cytomegalovirus in solid organ transplantation: epidemiology, prevention, and treatment. Curr Infect Dis Rep14:633-641.[aclr.com.es]
  • Pass R: Epidemiology and transmission of cytomegalovirus. J Infect Dis 1985; 152:243-8.[anesthesiology.pubs.asahq.org]
  • Epidemiology Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
  • Our research in immunocompromised patients takes a multifaceted approach to identifying epidemiologic risk factors for CMV infection, defining the viral kinetics, and improving prevention, diagnosis and treatment strategies.[research.fhcrc.org]
Sex distribution
Age distribution

Pathophysiology

  • ., bone marrow, lungs, kidneys) References: [1] [2] [3] Pathophysiology Clinical features CMV infection is usually asymptomatic. Severe manifestations occur in immunocompromised states (e.g., following organ transplantation, AIDS ).[amboss.com]
  • Because BOOP represent way in which the lung may respond to an inflammatory stimulus, the key pathophysiological findings are related to the inflammatory pathway.[aclr.com.es]
  • The role viremia plays in the pathophysiology of CMV disease is unknown. Life-threatening CMV pneumonia may develop in immunocompromised patients, with the incidence varying based on the type of transplant received.[emedicine.medscape.com]
  • Pathophysiology After the initial infection, CMV remains in a persistent state in the host. The cells of the myeloid lineage constitute an important reservoir.[ispub.com]
  • Pathophysiology Causal agent CMV or HHV-5 (type 5 of Human Herpes Virus) is a double-stranded DNA virus. It is the largest of the human herpes viruses with a 230 kb genome encoding 165 genes [ 11 ].[omicsonline.org]

Prevention

  • In addition, the use of ganciclovir is becoming increasingly important as an early means of preventing serious disease.[ncbi.nlm.nih.gov]
  • Intensified measures for prevention of CMV should be considered for patients at high risk of developing CMV pneumonia.[ncbi.nlm.nih.gov]
  • BACKGROUND: Despite major advances in the prevention of cytomegalovirus (CMV) disease, the treatment of CMV pneumonia in recipients of hematopoietic cell transplant remains a significant challenge.[ncbi.nlm.nih.gov]
  • We propose that antiviral "stand-by" memory-effector T cells persist in the lungs to prevent virus recurrence from latency.[ncbi.nlm.nih.gov]
  • Viral Pneumonia and ARDS;Viruses in the Immunocompromised; Atypical Bacterial Pneumonia; Other Community Respiratory Viruses; Pandemic Viruses; Epidemic and Emerging Coronaviruses; Post-Viral Complications; Antiviral Treatments; and Vaccines in the Prevention[books.google.com]

References

Article

  1. Kotloff RM, Ahya VN, Crawford SW. Pulmonary complications of solid organ and hematopoietic stem cell transplantation. Am J Respir Crit Care Med. 2004;170(1):22–48.
  2. Singh N, Dummer JS, Kusne S, et al. Infections with cytomegalovirus and other herpesviruses in 121 liver transplant recipients: transmission by donated organ and the effect of OKT3 antibodies. J Infect Dis. 1988;158(1):124–131.
  3. Vigil KJ, Adachi JA, Chemaly RF. Viral pneumonias in immunocompromised adult hosts. J Intensive Care Med. 2010;25(6):307–326.
  4. Boeckh M, Ljungman P. How we treat cytomegalovirus in hematopoietic cell transplant recipients. Blood. 2009;113(23):5711–5719.
  5. Moon JH, Kim EA, Lee KS, Kim TS, Jung KJ, Song JH. Cytomegalovirus pneumonia: high-resolution CT findings in ten non-AIDS immunocompromised patients. Korean J Radiol. 2000;1(2):73–78.
  6. Franquet T, Lee KS, Muller NL. Thin-section CT findings in 32 immunocompromised patients with cytomegalovirus pneumonia who do not have AIDS. AJR Am J Roentgenol. 2003;181(4):1059–1063.
  7. Zhao XS, Liu DH, Xu LP, et al. [Clinical features of cytomegalovirus pneumonia after allogeneic hematopoietic stem cell transplantation] Beijing Da Xue Xue Bao. 2009;41(5):548–553.

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Last updated: 2019-07-11 20:32