Grand Rounds

Disseminated Cytomegalovirus infection in an infant with congenital heart disease - Management issues

Sheryl Chettiar¹, Reepa Agarwal¹, Aditi Gupta¹, Alpana Utture², Ira Shah^1
1Department of Pediatric Infectious Diseases, B J Wadia Hospital for Children, Mumbai, India, ²Department of Neonatology, B J Wadia Hospital for Children, Mumbai, India

Address for Correspondence: Sheryl Vincent Chettiar, Vasant Galaxy, Mars-C-Wing, Flat No: 402, Bangur Nagar, Goregaon (W), Mumbai. Email: sherylchettiar12@gmail.com

Keywords: CMV, Paraneonate, CMV hepatitis

Clinical Problem:
A 2-month-21-day old male infant presented with respiratory distress, jaundice for 4 days, intermittent clay-coloured stools for 12 days and one episode of convulsion. He was diagnosed with moderate ventricular septal defect via echocardiography on 25^th day of life and was on furosemide and digoxin. He was born at term via vaginal delivery with birth weight of 2.4 kgs. An elder sibling died at 3 months of age due to congenital heart disease with neonatal hepatitis. On examination, the baby was 3.1 kgs, had jaundice with hepatomegaly and pansystolic murmur. Other systems were normal. Investigations are depicted in Table 1. He was given intravenous (IV) levetiracetam and was on non-invasive ventilation for 3 days, shifted to non-invasive ventilation using pressure control for next 5 days followed by continuous positive airway pressure. He then had 1 episode of desaturation, worsening distress and seizure requiring re-intubation. High-resolution computed tomography of chest and pulmonary angiogram showed 1 cm wide patent ductus arteriosus inserting to left pulmonary artery origin, complete collapse of right upper lobe (RUL), mucoid impaction in RUL bronchus causing luminal occlusions and consolidations in lower lobes. Electroencephalogram was normal. Airway assessment suggested minimal posterior subglottic injury. Blood TORCH polymerase chain reaction (PCR) was positive for cytomegalovirus (CMV). Bronchoalveolar Lavage (BAL) culture was positive for Klebsiella Pneumoniae >10⁵ CFU/ml. BAL CMV PCR showed viral load of 38225 IU/ml, with log of 4.5. Ophthalmological and hearing assessment were normal. Ultrasound abdomen showed increased echotexture of liver with mild hepatomegaly, right pelvi-ureteric junction obstruction with scattered internal echoes suggesting pyelonephritis. Urine routine showed 6-8 pus cells/hpf, bile salts and bile pigments. Liver biopsy showed fibrous expansion of portal areas with chronic inflammation, extensive intrahepatic cholestasis and giant cell transformation of hepatocytes with Metavir F2. Liver CMV viral load was 140425 IU/ml, log of 5.1. He was treated with IV gancyclovir, IV antibiotics, ursodeoxycholic acid and fat soluble vitamins. Thus, this child was detected to have disseminated CMV with CMV pneumonia, CMV viremia and CMV hepatitis.

Table 1. Serial Laboratory parameters of the patient.

Laboratory parameters	Day 1	Day 5	Day 12	Day 13	Day 18	Day 21	Day 25	Day 28	Day 31
Haemoglobin (g/dL)	9.3	8.2	7.2	9.3	7.4	10.5	10.2	15.8	13.4
PCV (%)	29	26	22	28.7	23	31.9		47	40.7
TC (K/uL)	17240	13000	9710	8416	10500	12170	7060	13300	9980
Polymorphs (%)	39.1	45	40	50	57	63.3	76	86	75
Lymphocytes (%)	52.8	41	48	38	38	29.3	20	11	22
Monocytes (%)	6.8	10	11	10	5	5.3	2.7	1	2.9
Eosinophils (%)	0.2	2.5	0.7	16	1	2.1	0	0	0
Platelet count (K/uLl)	684	5.6 L	4.5L	366	405	5.48L	4.4L	2.1 L	2.1 L
C-reactive protein (mg/L)	0.6	1.5	0.6	2.5		1.4	1.1	2.5	32.3
SGOT (U/L)	165	87	89		61	89	133	157
SGPT (U/L)	157	89	84		82	115	136	88
Albumin (g/dL)	4.2	3.5	3.4				3.7	3.3
Bilirubin- T/D (mg/dL)	10.1/9.5	13.9/12.8	11.9/10.6	9.6/20		14.3/3.6	14.5/13.1	18.9/16	15.3/14
BUN (mg/dL)	18	11	13				20	39	33
Creatinine (mg/dL)	0.43	0.2	0.3				0.45	0.60	0.45
Lactate (mmol/L)	3	1.3				1.5	6.8	3.4	1.65

NOTE: PCV- Packed Cell Volume, TC- Total Count, BUN-Blood Urea Nitrogen.

Is this congenital (cCMV) or acquired CMV (aCMV)? How to treat it?