Cytomegalovirus reactivation in a critically ill patient: a case report

Abstract

BackgroundThe aim of this case report is to discuss diagnostic workup and clinical management of cytomegalovirus reactivation in a critically ill immunocompetent pediatric patient.Case presentationA 2-year-old white boy who had no medical history presented with respiratory distress and fever. His Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores were 20 and 11, respectively. Our preliminary diagnosis was multiple organ dysfunction secondary to sepsis. Antibiotic treatment was started; he was intubated and artificially ventilated. Norepinephrine infusion was started. Hemophagocytic lymphohistiocytosis was diagnosed because our patient had elevated levels of serum ferritin, bicytopenia, splenomegaly, fever (> 38.5 °C), and hemophagocytosis shown in a bone marrow sample. Therapeutic plasma exchange and intravenously administered high-dose corticosteroid for hemophagocytic lymphohistiocytosis and continuous renal replacement treatment for acute renal failure were initiated. Following 5-day high-dose corticosteroid administration, therapeutic plasma exchange, and continuous renal replacement treatment, his clinical status and kidney and liver functions improved, and vasoactive requirement and ferritin levels decreased. He was extubated on the seventh day. On the tenth day of hospitalization he had a seizure and was diagnosed as having septic encephalopathy. His immune functions were found to be normal. Although his medical condition improved continuously, he had left spontaneous pneumothorax on the 21st day of admission as a complication of necrotizing pneumonia. Since pneumothorax persisted, left upper lobectomy surgery was performed on the 30th day of hospitalization. In the pathological examination of the excised lung tissue, features of cytomegalovirus infection were observed. Ganciclovir treatment was started. Serological tests indicated that our patient had cytomegalovirus reactivation. Antiviral treatment was stopped after 17 days, when cytomegalovirus deoxyribonucleic acid (DNA) polymerase chain reaction results became negative. He fully recovered and was discharged on the 50th day of admission.ConclusionsCytomegalovirus reactivation in critically ill patients is a prevalent problem and shown to be associated with higher mortality and morbidity. In a case of serologic detection of cytomegalovirus reactivation without any clinical sign of infection, pre-emptive treatment could be considered with assessment of risks and benefits for each patient. Antiviral therapy is highly recommended for patients who have risk factors identified.

Epidemiological and Liver Biomarkers Profile of Epstein-Barr Virus Infection and Its Coinfection with Cytomegalovirus in Patients with Hematological Diseases

“…Kogawa et al (2014) reported high serum levels of bilirubin and ferritin in EBVinfected children carriers of hemophagocytic lymphohistiocytosis, which worsened the prognosis of the disease [25]. Also, increased levels of serum ferritin were found in CMVinfected individuals and patients with acute mononucleosis [26][27][28][29]. In this study, high levels of serum ferritin were associated with EBV infection and EBV/CMV coinfection.…”

A new indicator: The diagnostic value of CD8+T/B lymphocyte ratio in sepsis progression

“…Persistent NK cell dysfunction was closely related to sepsis induced immunosuppression, making patients more prone to secondary infection or latent virus reactivation and leading to poorerprognosis. 40,41 This also explained the sequential decrease in the absolute values of NK cells in the three groups.…”

“…Persistent NK cell dysfunction was closely related to sepsis induced immunosuppression, making patients more prone to secondary infection or latent virus reactivation and leading to poorerprognosis. 40,41 This also explained the sequential decrease in the absolute values of NK cells in the three groups.

Figure 4.Comparison of the proportion of peripheral blood lymphocyte subpopulation in each group. The data were averaged and tested by Mann–Whitney U test.

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Identifying Potential Effective Diagnostic and Prognostic Biomarkers in Sepsis by Bioinformatics Analysis and Validation

“… 28 It has been found that reduced and dysfunctional NK cells are closely associated with sepsis-induced immunosuppression, leading to a greater susceptibility to infection and a poorer prognosis for patients. 29 , 30 It is evident that these intrinsic immune cells play an important role in the regulation of inflammation in sepsis. On the other hand, sepsis increases apoptosis, which may lead to a decrease in the number of CD4 T cells, 31 and significantly reduces the proliferative capacity of CD4 T cells.…”