Cytomegalovirus pneumonitis amid COVID-19 chaos: the hidden enemy—a case report

Abstract

Background The effect of coronavirus disease 2019 on the immune system is increasingly recognized. When severe, it causes immune dysregulation that may favor other infections, including Herpesviridae. Cytomegalovirus shares many innate immune pathways with severe acute respiratory syndrome coronavirus 2, which may potentiate each other. We describe a case of cytomegalovirus pneumonitis complicating the course of coronavirus disease 2019 in a patient with systemic lupus erythematosus/systemic sclerosis overlap and usual interstitial pneumonia, mimicking interstitial lung disease exacerbation. To the best of the authors’ knowledge, this is the first case to be reported worldwide in the setting of connective tissue disease-associated interstitial lung disease. Case description We describe the case of a 47-year-old white/Yemeni female who is known to have systemic lupus erythematosus/scleroderma overlap and usual interstitial pneumonia who was initially admitted with severe coronavirus disease 2019 pneumonia mandating intensive care. After initial improvement, it was later complicated with cytomegalovirus pneumonitis, mimicking interstitial lung disease exacerbation. The case was successfully treated with ganciclovir. Conclusion Intriguingly, severe acute respiratory syndrome coronavirus 2 and cytomegalovirus may potentiate each other, since they share some innate immune pathways. Subjects with severe coronavirus disease 2019 and underlying connective tissue diseases and those who are immunosuppressed carry higher risk compared with other cohorts, which may mandate active surveillance for cytomegalovirus coinfection or reactivation. Among various immunosuppressive therapies that has been tried for cytokine storm, use of anti-interleukin-6 inhibitors in the aforementioned population may carry more harm than previously thought, which may suggest that is reasonable to omit its use in treating this group with coronavirus disease 2019. This case underlines an underrecognized and underreported cause of morbidity and mortality during the course of severe coronavirus disease 2019 and will help to alert clinicians of its occurrence.

Viral reactivations and co-infections in COVID-19 patients: a systematic review

“…Undetectable viremia from an initial molecular testing followed by the detection of CMV DNA in a subsequent testing [ 17 , 63 , 66 , 70 , 82 ], or CMV DNA detection and seropositive for either IgG or IgM [ 41 , 51 ] or both [ 41 ], or detection of CMV DNA alone when prior testing for the absence of viremia is not available [ 15 , 23 , 42 , 44 , 60 , 62 , 81 ]…”

In silico analysis of genomic landscape of SARS-CoV-2 and its variant of concerns (Delta and Omicron) reveals changes in the coding potential of miRNAs and their target genes

“…KEGG pathways like human cytomegalovirus infection, breast cancer, apoptosis, axon guidance, neurotrophin signaling pathway, and acute myeloid leukemia were found to be unique for Delta whereas the sphingolipid signaling pathway was found for the Omicron. The predicted miRNAs may affect genes that cause the coinfection or reactivation of Cytomegalovirus infection, which is reported widely during the COVID-19 and thought to be related to overlapped innate immune pathways and reactivation by inflammation ( Alanio, 2022 , Aldehaim et al, 2022 ). The other important unique pathway found in our study is the axon guidance pathway, the genes of which might be regulated by predicted miRNAs.…”

Is SARS-CoV-2 Infection Causing the Reactivation of Cytomegalovirus?

“…6,7 In addition, CMV shares many innate immune pathways with SARS-CoV-2, which may reinforce each other. 8…”

“…6,7 In addition, CMV shares many innate immune pathways with SARS-CoV-2, which may reinforce each other. 8 It is also important to draw our attention to the possible false-positive results of the IgM test. IgM antibodies are pentamers (with 10 antigen-binding epitopes), and their structural characteristics lead to IgM efficiently binding to antigens (specific or nonspecific) and possible cross reactivity.…”