Cytomegalovirus encephalomyelitis: MR imaging findings documenting response to ganciclovir therapy.

Abstract

A CNS infection due to cytomega lovirus (CMV) is typically seenin individualswith AIDS and is un common in individuals who are immunosup pressed for other reasons. In general, brain infection by CMV is more common than spinal infection, and the latter is usually manifested by spinal nerve root involvement (i.e., polyradicu litis) [1]. We report the MR imaging findings in an immunosuppressed patient without AIDS in whom clinical and imaging findings were located predominantly in the spinal cord rather than in the brain or spinal nerve roots.The imaging findings of CMV encephalo myelitis are important to recognize because early specific therapy may be life-saving. Case ReportA left breastmasswasfoundat mammogra phy in a 51-year-old woman and was diag nosed as carcinoma by needle biopsy. She underwent left mastectomy and axillary node dissection, which showed multiple lymph nodes positive for the presence of carcinoma. She was treated with a regimen of cyclophos phamide,methotrexate,and 5-fluorouracil. Six years later she developed a left chest wall mass. Fine-needle biopsy showed metastatic breast carcinoma, and she was treated with doxorubicin for 3 months, with a marked de crease in the size of the mass, followed by treatment with cisplatin, carmustine, and cy clophosphamide with stem-cell rescue. Two weeks after completion of chemotherapy, she began to experience leg paresthesias that were initially thought to represent effects of chemo therapy. The paresthesias slowly progressed over the next 6 weeks, consistent with cisplatin sensory polyneuropathy. However, over the course of 1 week, rapidly progressive leg anes thesia, paraparesis,and urinary incontinence developed.Lumbar punctureand MR imaging findings of the brain and total spine 2 days af ter rapid onset of clinical deterioration were negative. The patient was then transferred to our institution for further examination.A secondMR imaging study on hospital day I (7 days after the initial MR imaging study) revealed multiple sites of hyperintense signal on T2-weighted images involving the cervical spinal cord and medulla (Fig. lÀ).On unenhanced TI-weighted images, the lesions appeared hypointense. After contrast adminis tration, the cervical spine lesions showed ring like enhancement,whereas those within the medulla showed nodular enhancement (Fig. lB). MR imaging of the brain did not reveal other lesions. Because of the possibility that the lesionsrepresentedintramedullary metastases, 18F-fluorodeoxyglucose positron emission to mography was performed on hospital day 8. No increasedmetabolic activity was seenwithin the lesions, and this finding was inter preted as evidence against metastasis. On the assumptionthat the myelopathy could be due to an inflammatoiy demyelinating process, corticosteroid therapy was started on hospital day 3. Follow-up MR imaging on hospital day 9 showed an increase in the size and contrast enhancement of the lesion. A sample of CSF from a secondlumbar punctureon hospital day 13 had positive findings for CMV as deter mined by p...

Central Nervous System Complications in Children Receiving Chemotherapy or Hematopoietic Stem Cell Transplantation

“…CMV ventriculitis is characterized by thin, smooth ependymal enhancement with associated debris within the ventricles. Despite not specific, retinal involvement or polyradicular or ependymal enhancement should raise suspicion of CMV infection (101). Ganciclovir (and its orally available prodrug, valganciclovir) and foscarnet are the most effective first-line agent for CMV treatment after HSCT.…”

Neuroimaging and Neurologic Complications after Organ Transplantation

“…Rarely, CMV may also lead to CNS infection that may manifest as polyradiculitis or encephalitis, and imaging features are fairly nonspecific 12 . Atypical rare presentation with ring‐enhancing lesions in brainstem and spinal cord has been reported as well 13 …”

“…Viral myelitides may have insidious onset and spinal MRI may be normal or show hyperintense spinal lesions on T2WI. Atypical CMV myelitis may present with ring‐enhancing lesions that are hypointense on T1WI MRI images 13 . Viral infections may also cause (poly)radiculitis (CMV, EBV).…”

“…12 Atypical rare presentation with ring-enhancing lesions in brainstem and spinal cord has been reported as well. 13 In transplant patients, primary or reactivated EBV infection may be associated with posttransplant lymphoproliferative disorder (PTLD) and EBV encephalitis is rare. Similarly as VZV, the manifestations of CNS infection caused by EBV are protean and may affect both central and peripheral nervous systems in many different ways including encephalitis, encephalomyelitis, myeloradiculitis, or even peripheral neuropathy.…”

“…Atypical CMV myelitis may present with ring-enhancing lesions that are hypointense on T1WI MRI images. 13 Viral infections may also cause (poly)radiculitis (CMV, EBV). Systemic or local fungal and bacterial infections may precipitate an epidural abscess leading to compressive myelopathy requiring immediate intervention.…”