Multiorgan involvement due to cytomegalovirus infection in AIDS

Abstract

Cytomegalovirus (CMV) infection is a relatively late complication of AIDS. Like other viruses contributing to comorbidity of HIV infection, cytomegalovirus has the propensity to cause multiorgan involvement. We report the case of a 34-year-old seropositive man who presented with bilateral lower limb weakness and symptomatic pallor. He was already on antiretroviral drugs for a month prior to presentation. Detailed clinical examination and laboratory investigations revealed cytomegalovirus polyradiculoneuropathy associated with bone marrow dysplasia. Dysplasia of haematopoeitic cell lines occurs in 30% to 70% of HIV infected patients, and is often indistinguishable from myelodysplastic syndrome. However, in our case, the bone marrow picture reverted back to normal with treatment of the CMV infection, pointing to a possible role of CMV as the causative agent of bone marrow dysplasia. Moreover, CMV has been incriminated as a pathogen producing the immune reconstitution inflammatory syndrome. The onset of the disease in our case one month after initiation of HAART strongly raises the possibility of this being a case of CMV related IRIS. This is the first reported case where IRIS has presented with CMV polyradiculoneuropathy and bone marrow dysplasia. We would like to highlight that in today's era of HIV care, clinicians should be aware of the possibility of multiorgan involvement by CMV, for appropriate management of this disease in the background of AIDS. Key-Words: AIDS, cytomegalovirus, multiorgan involvement.A 34-year male patient diagnosed seropositive for HIV-1 in 2003, presented to us in February 2006 with the main complaints of weakness of both lower limbs for 6 weeks. The weakness of his lower limbs was insidious in onset and gradually progressive over this period of time. He could stand on his own but was gradually finding it difficult to walk without assistance associated with a difficulty in getting up from sitting position. He further complained of an inability to feel his footwear and the ground that he was standing on. Moreover, he had involuntary slipping out of footwear on attempted walking. He had no history suggestive of any weakness or sensory loss in his upper limbs. The lower limb weakness was not associated with any sense of tightness, fasciculations, abnormal movements or any back pain. He gave no history suggestive of bladder or bowel involvement. He also complained of exertional dyspnea which had increased over the last four months and was now associated with swelling of both his feet. There was no history of wheeze, orthopnea, chronic diarrhea, postural dizziness or syncope. The patient had no addictions and had been married for 16 years. He has two living children. He describes an episode of skin disease strongly suggestive of zoster involving the ophthalmic division of the left trigeminal nerve about 3 years before. He was diagnosed with extrapulmonary tuberculosis involving the abdominal lymph nodes 14 months before for which he had received 6 months of WHO category 1 antitubercular ther...

Neurological complications of immune reconstitution in HIV‐infected populations

“…It is also a fairly common pathogen with seroprevalence rates between 50–80% 55 . Most commonly CMV is associated with CMV‐retinitis‐IRIS and has only been demonstrated in a few CNS‐IRIS cases 56–59 . In these cases ganciclovir was administered successfully and the patients recovered 56,57,59 .…”

“…Most commonly CMV is associated with CMV‐retinitis‐IRIS and has only been demonstrated in a few CNS‐IRIS cases 56–59 . In these cases ganciclovir was administered successfully and the patients recovered 56,57,59 . CMV can also cause a radiculitis or ventriculitis in immune‐suppressed patients with HIV infection; however, to date IRIS has not been reported with these conditions.…”

A Rare Complication of Cytomegalovirus Infection

“…There are only 3 additional cases of CMV-associated IRIS characterized by extraocular CNS involvement that have been published in the literature. [10][11][12] The clinical presentations for each of these patients were ventriculitis, cerebral vasculopathy, and polyradiculoneuropathy and their CD4 + counts at the time of HAART initiation ranged from 1 to 114 cells/μL. All had onset of neurological symptoms within 2 months of HAART initiation and the presence of CMV in the CNS was confirmed in all patients with CSF CMV DNA PCR.…”

“…15 As such, there have been no randomized, controlled trials conducted regarding clinical management of CNS IRIS and treatment remains on the basis of case reports and small case series. 16 In the 3 previously reported cases of CMV CNS IRIS, treatment was with ganciclovir either alone or in combination with foscarnet [10][11][12] and without corticosteroids. Although there were no deaths and all 3 patients eventually recovered, improvement in neurologic function was very gradual and only resolved after several weeks to months of continued anti-CMV therapy.…”

Immune reconstitution disease of the central nervous system

“…In one case of presumptive CMV ventriculitis IRD that occurred 10 days after commencing HAART, the patient responded well to a combination of intravenous ganciclovir and foscarnet therapy followed by valganciclovir maintenance [62]. A second case report details a patient with CMV polyradiculopathy that developed 1 month after commencing HAART, who made a full recovery with intravenous ganciclovir treatment [63].…”