Cytomegalovirus-associated myelitis in an emergency department patient with altered mental status

Abstract

Background

Cytomegalovirus (CMV) of the Herpesviridae family can occur in immunocompromised patients, including those with human immunodeficiency virus (HIV) and CD4 counts below 200 ​cells/microL. CMV-associated acute transverse myelitis is rare and can present with acute sensory changes, ascending weakness, and sphincter dysfunction.

Case report

A middle-aged female with uncontrolled HIV presented with altered mental status, inability to walk, and incontinence. On examination, she was significantly altered with focal neurological findings including nystagmus, bell's palsy, urinary retention, and leg weakness and numbness. Lumbar puncture results were positive for CMV infection, with transverse myelitis on magnetic resonance imaging, requiring hospital admission and treatment with ganciclovir. Unfortunately, her hospital course was complicated by immune-reconstitution inflammatory syndrome after initiation of antiretroviral medications, with prolonged significant debilitation including sensorineural hearing loss, neurogenic bladder requiring catheterization, and difficulty walking after hospital discharge.

Why should an emergency medicine physician be aware of this?

CMV infection presenting with both cranial and peripheral neuropathic involvement is a unique manifestation. Physicians should also recognize the diagnostic criteria for acute transverse myelitis, including spinal cord sensorimotor and autonomic dysfunction, a clearly defined sensory level, bilateral distribution, and inflammation noted on magnetic resonance imaging. This case highlights the importance of maintaining a broad differential in patients who present with altered mental status and performing a comprehensive neurological examination. In summary, physicians should quickly recognize the neurological findings of CMV infection and start urgent treatment to prevent permanent functional, neurological, and cognitive damage, especially in patients with HIV or immunocompromised status.