Medical Image of the Week: Cytomegalovirus Pneumonia

Figure 1. CT Chest, coronal cut showing left lower lobe consolidation.

Figure 2.  Pap stain highlights an enlarged cytomegalovirus-infected pneumocyte containing a single, dark intranuclear inclusion (arrow) with surrounding halo, giving the cell a characteristic “owl’s eye” appearance. Background cells consist of predominantly of macrophages and red blood cells (100x).

Figure 3. CMV-infected pneumocyte demonstrating an enlarged nucleus with a single dense intranuclear inclusion. The cytoplasm contains smaller basophilic inclusions with vacuolization and cytoplasmic projections (Pap stain, 100x).

A 29 year-old female with a history of systemic lupus erythematosus presented with a seven-day history of fever, dyspnea and a non-productive cough. She underwent renal transplantation four weeks prior to admission and was maintained on mycophenolate, tacrolimus, prednisone and prophylactic fluconazole, trimethoprim/sulfamethoxazole and valgangcyclovir. A CT chest was performed (Figure 1) and revealed left lower lobe consolidation. A BAL was performed in the left lower lobe and the cell count revealed 50% lymphocytes, 13% neutrophils and 37% macrophages. The BAL Papanicolaou stain showed enlarged cytomegalovirus-infected pneumocytes with the characteristic “owl’s eye” appearance (Figures 2 and 3). CMV quantitative PCR from serum resulted 648,615 IU/m.  The BAL culture grew CMV. The patient was started on treatment with valgangcyclovir with clinical improvement.

While often thought of as a “pneumonitis” with diffuse infiltrates, CMV can cause a lobar pneumonia in up to 30% of patients.  Prophylaxis is effective, but cases can occur despite a preemptive strategy.

Nathaniel Reyes MD^*, Julianna J. Weiel MSII⁺, Erika R. Bracamonte MD⁺, Linda Snyder MD^*
Department of Medicine, Division of Pulmonary and Critical Care Medicine*
Department of Pathology⁺

University of Arizona

Tucson, Arizona

Reference

Kang E, Patz E, Miller NL. Cytomegalovirus pneumonia in transplant patients: CT findings. J Comput Assisted Tomogr. 1998:20:295-9. [CrossRef]

Reference as: Reyes N, Weiel JJ, Bracamonte ER, Snyder L. Medical image of the week: cytomegalovirus pneumonia. Southwest J Pulm Crit Care. 2013;7(4):221-2. doi: http://dx.doi.org/10.13175/swjpcc131-13 PDF

Comments

[Maria]

Cytomegalovirus (pronounced sy-toe-MEG-a-low-vy-rus), or CMV, is a common virus that infects people of all ages. Over half of adults by age 40 have been infected with CMV. Once CMV is in a person’s body, it stays there for life and can reactivate. Most people infected with CMV show no signs or symptoms. However, CMV infection can cause serious health problems for people with weakened immune systems, as well as babies infected with the virus before they are born