Nonspecific radiographic manifestations of cytomegalovirus infection in 4 HIV-positive adults – diagnosis through transbronchial biopsy

Abstract

A 45-year-old man with a history of previous tuberculosis (TB) infection presented with a cough and chest pain. Sputum results and blood cultures were negative. The chest radiograph (CXR) demonstrated bilateral multifocal areas of patchy airspace disease, as well as a dominant focal area of density in the right upper lobe (Fig. 1). No effusions were noted. A presumed diagnosis of PJP was made, but the patient did not respond to treatment. Bronchoscopic biopsy confirmed CMV infection. CASE 2A 43-year-old woman with no history of TB or TB contacts presented with a cough and haemoptysis, loss of weight, low fever and rigors. The white cell count (WCC) was 6.4×10 9 /l, and sputum results and blood cultures were negative. The CXR revealed bilateral reticular-nodular and ground-glass opacities without any effusions ( Fig. 2, a). The differential diagnosis included TB and PJP. Bronchoscopic biopsy confirmed the diagnosis of both CMV and PJP infections. CASE 3A 30-year-old woman presented with shortness of breath, a dry cough, loss of weight and fever. The WCC was 13×10 9 /l and the CD4 count 481 cells/µl. The CXR demonstrated bilateral reticular and ground-glass opacities (Fig. 2, b). Treatment for TB and PJP was started, but the patient showed no clinical improvement. Bronchoscopic biopsy confirmed both CMV and pneumocystis pneumonia (PCP). CASE 4A 29-year-old woman presented with a cough, chest pain, loss of weight and shortness of breath. The WCC was 9.1×10 9 /l and the CD4 count 14 cells/µl. On the CXR there were bilateral, diffuse, reticular and airspace shadows with no effusions (Fig. 2, c). Both TB and PJP were considered in the differential diagnosis. Transbronchial biopsy revealed CMV and PJP infections.Transbronchial biopsy in all patients demonstrated alveolar tissue containing CMV with nuclear and cytoplasmic inclusions (Fig. 3). This was accompanied by alveolitis and an associated inflammatory cell infiltrate NONSPECIFIC RADIOGRAPHIC MANIFESTATIONS OF CYTOMEGALOVIRUS INFECTION IN 4 HIV-POSITIVE ADULTS -DIAGNOSIS THROUGH TRANS-BRONCHIAL BIOPSY Matthew Goodier, MB ChBGrace Rubin, MB BCh, DA (SA), FCRad (Diag) (SA) Department of Radiology, University of the Witwatersrand, JohannesburgWe report on 4 HIV-positive adult patients who presented (over a 2-year period) with clinically significant cytomegalovirus (CMV) pneumonia requiring transbronchial biopsy for diagnosis. The patients were not on antiretroviral therapy. Clinical findings were nonspecific, sputum samples were negative, blood test results were non-contributory, and empirical treatment had failed. Radiological findings were extensive but nonspecific. Three of the 4 patients were co-infected with Pneumocystis jirovecii (PJP) pneumonia, further confounding the radiological diagnosis.