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AN UNUSUAL CASE OF CYTOMEGALOVIRUS PNEUMONIA IN A PATIENT WITH COVID-19 REQUIRING EXTRACORPOREAL MEMBRANOUS OXYGENATION
Chest ; 162(4):A755, 2022.
Article in English | EMBASE | ID: covidwho-2060683
ABSTRACT
SESSION TITLE COVID-19 Co-Infections SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/19/2022 1245 pm - 145 pm

INTRODUCTION:

Human cytomegalovirus (CMV) is a herpesvirus with a high prevalence that causes latent disease in immunocompetent hosts. It is an important opportunistic infection with a variety of clinical manifestations, including pneumonia, in immunocompromised patients.[1] CASE PRESENTATION A 45-year-old man with no past medical history presented with fever and dyspnea and was positive for coronavirus disease 2019 (COVID-19). He developed acute respiratory distress syndrome (ARDS) and was intubated 13 days after presentation, but developed refractory hypoxemia requiring veno-venous extracorporeal membrane oxygenation (ECMO) (cannulated 16 days after presentation). He received a 5-day course of remdesivir and 10 days of dexamethasone 6 mg daily. His course was complicated by acute renal failure requiring continuous renal replacement therapy, septic shock due to a pseudomonal ventilator-associated pneumonia, right ventricular failure, heparin induced thrombocytopenia, and right pneumothorax requiring chest tube thoracostomy. After 4 weeks of ECMO there was lung recovery with ECMO sweep gases <1L/minute, improved radiographic appearance and tidal volumes, and decannulation was anticipated. However, he subsequently developed profound shock of unknown etiology with a rapid worsening of his lung function requiring increased ECMO support. Care was withdrawn at ECMO day 46 due to multiorgan failure. Pathology of his lungs at autopsy showed prominent intranuclear viral inclusions and positive immunohistochemistry in alveolar macrophages consistent with a diagnosis of CMV pneumonia.

DISCUSSION:

While CMV typically causes latent disease it can reactivate in the setting of immunosuppression and/or critical illness.[1] Patients with severe COVID-19 frequently are treated with immunosuppressive therapies, such as corticosteroids, anti-interluekin-6 therapies, and JAK inhibitors. Due to this immunosuppression, opportunistic infections have been reported in these patients.[2] It can be difficult to differentiate COVID-19 pneumonia from other respiratory infections based on imaging and lab studies alone, especially in patients with prolonged mechanical ventilation and with severe parenchymal disease requiring ECMO support. Little is known about the incidence of CMV and COVID-19 coinfection. There are several cases of biopsy-proven CMV pneumonia in immunocompromised critically ill patients with COVID-19, but this is the first reported case in an immunocompetent patient.

CONCLUSIONS:

This case highlights the need to maintain a high degree of suspicion for CMV pneumonia in patients with severe COVID-19 pneumonia who receive immunosuppressive therapies. While the diagnosis was made at autopsy in this case, it may be possible to arrive at an earlier diagnosis with CMV polymerase chain reaction (PCR) assays sent from the serum and bronchoalveolar lavage (as lung biopsies are usually impractical in ARDS). Reference #1 de la Hoz RE, Stephens G, Sherlock C. Diagnosis and treatment approaches of CMV infections in adult patients. J Clin Virol. 2002 Aug;25 Suppl 2S1-12. doi 10.1016/s1386-6532(02)00091-4. PMID 12361752. Reference #2 Abdoli A, Falahi S, Kenarkoohi A. COVID-19-associated opportunistic infections a snapshot on the current reports [published online ahead of print, 2021 Aug 23]. Clin Exp Med. 2021;1-20. doi10.1007/s10238-021-00751-7 DISCLOSURES No relevant relationships by Nancy Law No relevant relationships by Mazen Odish No relevant relationships by Robert Owens No relevant relationships by Travis Pollema No relevant relationships by Alyssa Self No relevant relationships by Cassia yi
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Full text: Available Collection: Databases of international organizations Database: EMBASE Language: English Journal: Chest Year: 2022 Document Type: Article

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Full text: Available Collection: Databases of international organizations Database: EMBASE Language: English Journal: Chest Year: 2022 Document Type: Article