Matias-Lopes Inês, Atalaia-Barbacena Henrique, Guiomar Margarida, Soares Raquel, Barão Catarina, Ferreira Ana Rita, Parlato Federica, Howell-Monteiro Patrícia
Department of Internal Medicine, Hospital de Santa Maria, ULS de Santa Maria, Lisbon, Portugal.
Faculty of Medicine University of Lisbon, Lisbon, Portugal.
Eur J Case Rep Intern Med. 2024 Dec 16;11(12):005071. doi: 10.12890/2024_005071. eCollection 2024.
Cytomegalovirus (CMV) is a human herpes virus with a worldwide seroprevalence of 60-100%, mainly known to cause severe life-threatening disease in immunocompromised patients. In immunocompetent hosts (IMCh), CMV causes a self-limiting mononucleosis-like infection, and severe pictures are less recognized. We report a case of a previously healthy 62-year-old woman evaluated in the Internal Medicine outpatient clinic for 3 weeks of progressive fatigue, generalised inflammatory arthralgias, hypogastric discomfort and daily persistent fever. On first examination, paleness and hepatomegaly were noted. Further evaluation showed the presence of haemolytic anaemia; lymphocytosis and monocytosis; thrombocytosis; elevated C-reactive protein; hypertriglyceridemia and hyperferritinaemia; peripheral blood immunophenotyping with a 44% population of T cells and diminished CD4/CD8 ratio. Hemophagocytic lymphohistiocytosis (HLH) was suspected, with an Hscore of 190 points, giving a 70-80% probability. CMV serology was positive for acute infection (IgM positive/IgG negative), with a viral load of 4470 IU/ml. CMV primary infection was admitted, complicated with haemolytic anaemia, cholestatic hepatitis and possible HLH. Despite the laboratory frame exuberance, the patient remained stable and was discussed with Infectious Diseases, deciding not to initiate antiviral therapy. Over the next month, the fever, anaemia and hepatitis resolved, and the white blood cell count normalized. After two months, the CMV viral load was negative, and seroconversion was documented. Primary CMV infection is unusual in older patients. Additionally, in IMCh infection is usually mild, and severe infections are rare. In such cases, the use of antiviral therapy is not well established, and risk/benefit must be considered in a personalised approach. Altogether, the clinical and laboratory presentation of this case reinforces the need for high clinical suspicion.
Cytomegalovirus can have serious, and life-threatening manifestations in immunocompetent hosts and its incidence may be higher than previously thought.Despite its seroprevalence ranging near 100% in the global population, primary infection in the elderly immunocompetent hosts is uncommon, but not impossible.Antiviral treatment is not well established in non-life-threatening disease in immunocompetent hosts, and a personal and individual approach must be considered with risk/benefit consideration.
巨细胞病毒（CMV）是一种人类疱疹病毒，全球血清阳性率为60%-100%，主要在免疫功能低下的患者中引起严重的危及生命的疾病。在免疫功能正常的宿主（IMCh）中，CMV引起一种自限性的单核细胞增多症样感染，严重的病例较少见。我们报告一例病例，一名62岁的既往健康女性在内科门诊接受评估，她有3周的进行性疲劳、全身性炎性关节痛、下腹部不适和每日持续性发热。首次检查时，发现面色苍白和肝肿大。进一步评估显示存在溶血性贫血；淋巴细胞增多和单核细胞增多；血小板增多；C反应蛋白升高；高甘油三酯血症和高铁蛋白血症；外周血免疫表型分析显示T细胞占44%，CD4/CD8比值降低。怀疑为噬血细胞性淋巴组织细胞增生症（HLH），H评分为190分，概率为70%-80%。CMV血清学检查显示急性感染阳性（IgM阳性/IgG阴性），病毒载量为4470 IU/ml。确诊为CMV原发性感染，并发溶血性贫血、胆汁淤积性肝炎和可能的HLH。尽管实验室检查结果明显，但患者病情稳定，并与传染病科进行了讨论，决定不启动抗病毒治疗。在接下来的一个月里，发热、贫血和肝炎症状消退，白细胞计数恢复正常。两个月后，CMV病毒载量为阴性，并记录到血清学转换。原发性CMV感染在老年患者中不常见。此外，在免疫功能正常的宿主中，感染通常较轻，严重感染罕见。在这种情况下，抗病毒治疗的应用尚未明确，必须以个性化的方法考虑风险/收益。
巨细胞病毒在免疫功能正常的宿主中可出现严重的、危及生命的表现，其发生率可能高于此前的认识。尽管其在全球人群中的血清阳性率接近100%，但在老年免疫功能正常的宿主中，原发性感染并不常见，但并非不可能。在免疫功能正常的宿主中，抗病毒治疗在非危及生命的疾病中尚未明确，必须考虑个性化的方法并权衡风险/收益。
