What are the clinical manifestations of cytomegalovirus (CMV) pneumonia?

Updated: Mar 24, 2021
  • Author: Zab Mosenifar, MD, FACP, FCCP; Chief Editor: John J Oppenheimer, MD  more...
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Answer

CMV pneumonia is usually mild in otherwise healthy individuals. It starts as a mononucleosis-like syndrome (eg, malaise, fever, myalgias) with mild hepatitis and no lymphadenopathy or splenomegaly.

In immunocompromised people, the clinical picture may vary. Most commonly, asymptomatic shedding affects pulmonary secretions, blood, and urine, with no clinical significance and low mortality rates.

CMV syndrome manifests with self-limited fever and constitutional symptoms (fever, malaise, anorexia, myalgias, arthralgias, fatigue). CMV syndrome precedes CMV pneumonitis by 1-2 weeks and usually has a sudden onset, with respiratory complaints (cough, dyspnea, tachypnea), fever, an increased A-a gradient, and radiologic infiltrates. The duration is less than two weeks. See the A-a Gradient calculator.

In allogeneic HSCT recipients, CMV disease presents post engraftment (30-99 d after transplantation) and late (≥ 100 d) in those with graft versus host disease and/or on higher-dose immunosuppressive therapy. CMV pneumonia is seen in 10-30% of such patients, and the median time to occurrence is 44 days after transplantation.

Autologous HSCT recipients are at much lower risk for CMV pneumonia, seen in only 1-9% of cases, oftentimes with milder symptoms.

Among solid organ transplant recipients, CMV pneumonia is most common in lung transplantations, ranging from 15-55% of cases. Typically, this pneumonia develops between day 15-60 post transplantation and is characterized by fever, cough, and hypoxia. In CMV donor-positive/recipient-negative cases, the onset and progression can be rapid.

Other solid organ transplantations are associated with low rates of CMV pneumonia: liver, 9.2%; heart, 0.8-6.6%; and kidney less than 1%.

For BMT recipients, risk factors include pretreatment seropositivity, total-body irradiation, certain immunosuppressive treatment, severe acute or chronic graft-versus-host disease, underlying disease (acute lymphoblastic leukemia [ALL] or chronic lymphocytic leukemia [CLL]). Patients with primary CMV infection and allogeneic HSCT are at increased risk for severe disease.

In HIV patients, the pathogenic significance of CMV is considered low, even in the condition of common identification of viruses in bronchoalveolar lavage (BAL) and biopsy specimens. CMV pneumonia is found in HIV patients with a CD4 count of less than 200 cells/µL. CMV is thought to be a co-pathogen to Pneumocystis jiroveci and a cause of alveolar hemorrhage in HIV patients (due to thrombotic microangiopathy).


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