Clinical evaluation of patients with inflammatory connective tissue diseases complicated by cytomegalovirus antigenemia

Abstract

We evaluated the occurrence of cytomegalovirus (CMV) infection and the background characteristics in twenty-three hospitalized patients with inflammatory connective tissue diseases including systemic lupus erythematosus, polymyositis/dermatomyositis, rheumatoid vasculitis, microscopic polyangitis, and Takayasu's arteritis. Cytomegalovirus antigenemia was demonstrated in 10 of 23 evaluable patients. Five of ten patients with CMV antigenemia developed symptomatic CMV disease (all cases of fever, two cases of liver involvement, two cases of interstitial pneumonia, and one case of unknown organ involvement), whereas the remaining five patients were asymptomatic. Most of CMV antigenemia-positive patients had been administered intravenous steroid pulse, or in combination with immunosuppressive agents intravenously or orally because of refractory disease activity. Particularly, in patients who received intravenous methylprednisolone pulse in combination with additional intravenous cyclophosphamide pulse, the incidence of CMV antigenemia was markedly higher (four out of four). Four of ten CMV antigenemia-positive patients simultaneously showed detection of Pneumocystis jiroveci in induced sputum by PCR, increase in level of serum beta-D-glucan and the finding of geographical ground-glass opacities on chest computed tomography. These findings suggested that patients with connective tissue diseases under intensive immunosuppressive therapies (intravenous steroid pulse in combination with additional intravenous cyclophosphamide pulse in particular) are highly susceptible to CMV infection and disease, and that patients complicated by CMV antigenemia are susceptible to combined opportunistic infection such as Pneumocystis pneumonia.

Usefulness of quantitative real-time PCR assay for early detection of cytomegalovirus infection in patients with ulcerative colitis refractory to immunosuppressive therapies

“…Indeed, there are several reports of reactivation of CMV in the plasma of patients with collagen disease and AIDS without gastrointestinal involvement of CMV infection. 7,19 Reactivation of CMV in the plasma does not reflect the involvement of CMV infection in UC. 20 Histologic examination is often considered the "gold standard" for diagnosing CMV infection in the gastrointestinal tract.…”

“…Several methods are used to diagnose CMV infection, including histologic examination, CMV antigenemia, and PCR assay. [7][8][9] Among them, CMV antigenemia and PCR assay using whole blood potentially reflect the reactivation of CMV in the whole body, but does not necessarily indicate CMV infection in the colonic mucosa. Indeed, there are several reports of reactivation of CMV in the plasma of patients with collagen disease and AIDS without gastrointestinal involvement of CMV infection.…”

“…[7][8][9] For diagnosis of CMV infection in the gastrointestinal tract, combined CMV antigenemia assay and detection of CMV inclusion bodies in biopsy specimens from the gastrointestinal mucosa by either hematoxylin and eosin (H&E) staining or immunohistochemistry (IHC) using anti-CMV monoclonal antibodies has been proposed. 1 It is often difficult, however, to accurately diagnose CMV infection in patients with UC, 10 even when using this combined diagnostic method.…”

Intestinal Perforation due to Concomitant Cytomegalovirus Infection during Treatment for Pneumocystis jirovecii Pneumonia in a Patient with Rheumatoid Arthritis

“…Connective tissue disease patients undergoing immunosuppressive therapy are susceptible to CMV infection (5,6). CMV pneumonia can occur even with low-dose MTX therapy (7).…”

“…Yoda et al also reported that 4 of their 10 CMV antigenemia-positive patients showed detection of P. jirovecii in induced sputum by PCR analysis, an increase in the serum beta-D-glucan level, and geographical ground-glass opacities on chest radiography (5), all suggesting that connective tissue disease patients with CMV infection are susceptible to combined opportunistic infection of P. jirovecii (5).…”