CLINICAL HIV AND AIDS JOURNAL (ISSN:2633-5476)

Cytomegalovirus is a major cause of morbidity and mortality in patients with AIDS and immunosuppressed patients. Diagnosis of CMV disease often requires tissue biopsy with histologic evidence of viral inclusions and inflammation. This paper reports a rare case of an HIV-infected patient with a history of anemia, who presented with a cavitary lesion in the lung that has diagnosed as CMV pneumonitis, associated with CMV colitis that eventually the patient developed Acute Inflammatory Demyelinating Polyneuropathy (AIDP). 

CMV; Pneumonia; Cavitary; HIV

Cytomegalovirus (CMV) pneumonia is among the leading causes of morbidity and mortality in immune suppressed patients [1,2].

In HIV patients, the presence of CMV in bronchoalveolar lavage (BAL) specimen is not usually indicated for CMV pneumonia [3,4] and definitive diagnosis relies on documented evidence of CMV infection in the pulmonary tissue specimen [5].

On the other hand, pneumonia, with CMV as the only pathogen in pulmonary tissue, has rarely occurred in patients with HIV [6,7]. Chest radiographic findings vary, including reticular or ground glass opacities, alveolar infiltration or nodular opacities but cavitary lesions are rare [8].

This paper reports an HIV-infected patient with a history of anemia, the cavitary lesion due to CMV pneumonitis, associated with CMV colitis that eventually developed acute inflammatory demyelinating polyneuropathy (AIDP). 

A 61-year-old HIV-positive woman was admitted to Masih Daneshvari Hospital, Tehran with a three-month history of anemia, weakness, dyspnea, cough, fever, chills, bone pain, weight loss (less than 10% of total body weight) and loss of appetite. A complete workup was done for fever, weakness, and anemia that was not diagnostic, Chest x-ray was suspicious to a small cavitary in the left upper lobe, but several sputum smears for M.tb were negative. Finally, HIV was confirmed by western blot test and she was referred to our center to rule out TB/AIDS. She has divorced 15 years ago, life-long non-smoker, non- drug abuser and without any exposure to TB. The patient seemed doesn’t have any risk factor for HIV

Considering her critical condition with fever and dyspnea plus HIV status (520000 copies/ml HIV plasma viral load with a CD4 count of 342), highly active antiretroviral therapy (HAART) including efavirenz, lamivudine, zidovudine were administered. Sputum and BAL smears/culture for acid-fast bacillus (AFB) was negative and also real-time PCR for MTB complex was negative too. Regarding chest X-ray finding including interstitial infiltration and cavitary lesion, bronchoscopy procedure was performed that was not diagnostic. BAL smear and culture were negative for bacterial and fungal pathogen and immune staining results for Pneumocystis jiroveci were negative.

The patient then underwent computed tomography (CT) guided the biopsy. Pathological study of the detected lesion revealed diffuse interstitial pneumonia in which pneumocytes lining thickened alveolar septa were enlarged with intra nuclear and intra cytoplasmic inclusion. Immuno staining of the specimen was positive for CMV (Figure 1). Tissue culture was negative for MTB complex using Ziehl–Neelsen staining and PCR. Moreover, she received colonoscopy because of abdominal pain that revealed the gross involvement of large intestine which was confirmed by pathology studies.

Virology studies showed positive plasma PCR for CMV (690 copies/mL CMV viral load) and positive CMV antigen (pp65-Ag), so ganciclovir (intravenous) was started and her condition improved gradually.

Brain CT scan was performed to exclude toxoplasmosis. PCR detection of Toxoplasma and Parvovirus B19 were also negative in a blood sample. 

Two months later, she developed weakness of lower extremities that progressed to upper extremities during three days and eventually as a result of the weakness of respiratory muscles, she was incubated in intensive care unit. At this time CMV PCR of plasma became negative. Cerebrospinal fluid (CSF) analysis was negative for herpes simplex virus 1&2 (HSV-1 and HSV-2), varicella-zoster virus (VZV), and CMV. CSF cell count was zero and protein was 50 mg/dl. In India ink preparation no cryptococcus identified. She gradually developed severe pancytopenia and acute renal failure and unfortunately, she was expired with the clinical picture of septic shock. Nerve conduction velocity tests for definitive diagnosis of AIDP could not be performed due to the patient’s critical condition.

Lung involvement is one of the main causes of morbidity and mortality in HIV patients [9]. Because of immune insufficiency states, infections are predominant and isolation of more than one organism is common during the autopsy, especially in advanced AIDS cases [10]. Although in endemic countries, tuberculosis is the most common etiology [11], Lung cavitary lesion with CMV is rare [12,13]. In one study, among 21 AIDS patients with cytopathologic evidence of CMV pneumonitis, only one patient had a cavitary lesion [10]. However, differentiation between CMV disease and bacterial infection still remains controversial. 

Salomon et al. [8] have reported 41% in-hospital mortality of CMV pneumonia treated with specific anti-CMV, other studies confirm the poor outcome of CMV pneumonia in HIV patients [14]. 

An autoimmune process, acute inflammatory demyelinating polyneuropathy (AIDP), may be associated with CMV infection in advanced HIV [15,16]. 

The classic presentation is a symmetric acute motor weakness in more than one extremity, coupled with that in the absence of long tract signs and sensory loss is suggestive of AIDP [17,18].

This is a case of CMV pneumonia with cavitary lesion confirmed by biopsy while another opportunistic infection in the lung especially mycobacterial infection was ruled out. Also, the extrapulmonary involvement of CMV was verified in this patient as positive plasma PCR for CMV and large intestine involvement. With Regard to the appropriate response to ganciclovir, unconfirmed AIDP and negative CMV assay in cerebral fluid, it is suggested that the patient was expired because of immune reconstitution syndrome after HAART administration. Cavitated pulmonary lesion is not common in HIV patients. Also, CMV pneumonitis with cavitary lesion makes this patient rare case of CMV infection in HIV positive, immune compromised person.  

The authors declare that they have no competing interests.

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