P3606 - An Owl-Eyed Perspective: CMV Viremia as a Cause of Critical Illness, Pancreatitis, and Marrow Granulomas in an Immunocompetent Patient

Gomathy A. Nageswaran, MBBS¹, Tanmay P. Gandhi, MBBS¹, Katie Moreaux, MD¹, Tyler Fugere, MD¹, Vignesh Krishnan Nagesh, MBBS², Brent Harbaugh, MD¹, Hazel Liverett, MD^1
1University of Arkansas for Medical Sciences, Little Rock, AR; ²Hackensack Meridian Palisades Medical Center, North Bergen, NJ

Introduction: Cytomegalovirus (CMV) is a double stranded DNA virus that usually causes asymptomatic disease in healthy adults but can be a rare cause of critical illness as well. Here, we present a case of severe CMV infection causing fever, pancreatitis and multi-organ dysfunction in an immunocompetent woman.

Case Description/Methods: A 57-year-old female with a history of coronary artery disease, thoracic aortic aneurysm post-repair, diverticulosis, and multiple urinary tract infections presented as a transfer from an outside hospital for fever of unknown origin. Her symptoms started as low-grade fevers which gradually progressed over four weeks. She was admitted to a local hospital after seizure-like activity at home and later intubated for hypoxic respiratory failure while on vancomycin and meropenem. After transfer to UAMS, an extensive infectious work-up was performed. CSF PCR was positive for parechovirus and CMV. A bronchoalveolar lavage fluid was positive for CMV by PCR. CT scan of the chest abdomen and pelvis showed multifocal infectious pneumonia, bilateral pyelonephritis, and colitis. A repeat CT performed after a few days additionally revealed acute pancreatitis with elevated lipase levels to 620 U/L ( normal 13-60 U/L). Extensive workup for auto-immune causes was negative. Bone marrow biopsy showed granulomas. She was treated with ganciclovir and a gradual improvement in symptoms was noted. She was extubated and transferred out of the ICU. Her mental status improved and she was switched to oral valganciclovir. At a follow-up visit one 35 days later, her serum CMV PCR copies had dropped from 22000 to undetectable and she continued to improve clinically.

Discussion: CMV can cause a wide spectrum of diseases including prolonged fever and pancreatitis in healthy adults. The gastrointestinal tract and the central nervous system are the most common sites of CMV involvement in immunocompetent adults. [1] non-necrotizing granulomas on bone marrow biopsy are rare, and the causes encompass a variety of conditions including CMV. [2]
References:
1.Saeed MI, Stephens R, Nwogbo O, Gani IY, Kapoor R, Doroodchi A. Cytomegalovirus pancreatitis in an immunocompetent patient. IDCases. 2020;22:e00932. Published 2020 Aug 18. doi:10.1016/j.idcr.2020.e00932
2.Eid A, Carion W, Nystrom JS. Differential diagnoses of bone marrow granuloma. West J Med. 1996;164(6):510-515



Disclosures:


Gomathy A. Nageswaran, MBBS¹, Tanmay P. Gandhi, MBBS¹, Katie Moreaux, MD¹, Tyler Fugere, MD¹, Vignesh Krishnan Nagesh, MBBS², Brent Harbaugh, MD¹, Hazel Liverett, MD¹. P3606 - An Owl-Eyed Perspective: CMV Viremia as a Cause of Critical Illness, Pancreatitis, and Marrow Granulomas in an Immunocompetent Patient, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.