Relevant Pericardial Effusion Caused by Cytomegalovirus Infection in An Immunocompetent Patient

A Case Report

Tabea Hutter; Dirk Springe; Lukas Ebnöther; Marcos Delgado

Disclosures

J Med Case Reports. 2018;12(14) 

In This Article

Discussion

We report the case of an otherwise healthy, immunocompetent patient, who suffered severe complications from an acute CMV reinfection. In immunocompetent patients, a CMV infection usually provokes symptoms resembling an infectious mononucleosis or does not cause any symptoms at all. However, a few reports have been published about severe complications, as in our case.

Cytomegalovirus belongs to the herpes viruses' family and has a linear, double-stranded DNA.[4] The overall prevalence of CMV is high. A study conducted in Germany from a population of healthy blood donors found a prevalence of 45.8%, with slightly more females than males being carriers of the virus.[5] Other sources suggest a prevalence of about 60%. In developing countries, the prevalence is predicted to be approximately 90%.[4] This infection is most commonly transmitted horizontally through saliva, sexual intercourse, blood transfusion or through an organ transplantation; nevertheless, vertical transmission is possible as well.[4] Immunocompromised patients are at an increased risk of suffering from symptomatic CMV disease.

The primary infection is followed by a latent phase of infection and the virus can be reactivated at a future point in time, particularly in the case of an impairment of the immune system.[4] A seroconversion of the IgM combined with a low IgG avidity and the corresponding clinical findings confirm a recent (within the previous 4 months) CMV primary infection. In contrast, a high IgG avidity suggests a CMV infection earlier on (more than 4 months ago). In the case of a CMV reinfection with a new virus strain, the laboratory findings include a new IgM seroconversion (which can take place up to 2 weeks after exposure to CMV) and high levels of IgG with a high IgG avidity. That was the constellation of symptoms seen in the patient discussed in this case report. A reinfection is not a rare event – a prospective study conducted on a population of healthy, seropositive women found a reinfection in 29% of the participants.[6]

Immunocompetent patients with a primary CMV infection either do not suffer from any symptoms or experience symptoms resembling an infectious mononucleosis caused by the EBV. Tonsillitis and lymphadenopathy occur less frequently in patients with a CMV infection than in patients with EBV. Asthenia, arthralgia, and fever are common in patients with a CMV infection, and laboratory findings typically include lymphocytosis and atypical lymphocytes. A slight impairment of the liver function with a small elevation of the transaminases occurs frequently as well.[1,4] However, in rare cases, severe complications can also occur in immunocompetent patients. Myopericarditis, pericardial effusion, hepatitis,[1,2] colitis, and central nervous system involvement with encephalitis, meningitis or transverse myelitis are possible. In rare cases, pulmonary or ocular involvements have been described. Furthermore, different hematologic disorders including symptomatic thrombocytopenia, hemolytic anemia, disseminated intravascular coagulation, myelodysplastic changes, pancytopenia, and ruptured spleen can occur.[3]

The appropriate therapy for a hemodynamically relevant pericardial effusion consists of an immediately performed, ultrasound-guided pericardial puncture and drainage of the effusion in the ICU.[7,8] In our patient, surgical intervention was preferred due to the existing hepatomegaly and increased risk of a liver injury.

As an acute CMV infection usually shows a self-limiting, oligosymptomatic course in immunocompetent individuals, antiviral therapy is typically not indicated for this group. Several case studies reported the successful use of antiviral medications such as ganciclovir, valganciclovir and foscarnet in previously healthy patients with severe organ-specific complications or a prolonged disease course. At present, there are no recommendations concerning the dosage and duration of antiviral therapy in immunocompetent patients. The severity of the disease has to be balanced against the medical toxicity separately for each individual.[3] In our patient, the clinical course was uncomplicated, and no antiviral therapy was required.

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