Cytomegalovirus pneumonia coexisting invasive pulmonary aspergillosis in an old aged diabetic patient after prolonged intensive care

Abstract

Introduction

Cytomegalovirus (CMV) pneumonia is an important cause of morbidity and mortality in transplant recipients, hematological malignancies on chemotherapy, and HIV-infected patients. Invasive pulmonary aspergillosis (IAP) occurs primarily in patients with severe immunodeficiency. Both infections have dramatically increased in the patients with impaired immune state associated with critically ill patients and those with chronic obstructive pulmonary disease.

Case description

The 93-year-old diabetic woman was admitted to the intensive care unit (ICU) due to urosepsis. Antibiotic therapy with piperacillin-tazobactam was given. As clinical progression to profound shock and multiple organ failure, high-dose vasopressors, hydrocortisone and fluid resuscitation were given. After short course of continuous venovenous hemofiltration was used, the hyperkalemia and metabolic acidosis were improved. The patient was maintained on regular haemodialysis. However, active gastric and duodenal ulcers with bleeding were identified by endoscopy. Hemostasis and high-dose pantoprazole infusion were given. As stable condition after ICU stay for one month, she was transferred to respiratory care center for weaning ventilator. However, CXR showed partial consolidation over bilateral lung, favoring inflammatory process. The sputum culture showed Acinetobacter baumannii and Aspergillus species. Meanwhile, the results of CMV-PCR for serum and sputum samples were positive. Blood CMV virus load was 8140IU/mL. In spite of one week therapy with imipenem and ganciclovir, the sepsis and pneumonia did not improve. The CXR still showed severe pulmonary edema and high airway pressure was noted. The serum Aspergillus galactomannan (GM) antigen revealed >5.59 index (normal, <0.5). As rapid deterioration of clinical conditions, the families agreed palliative treatment and she died after 43 days of hospitalization.

Conclusion

Early diagnosis and treatment of CMV infection is important in view of the poor prognosis of established infection. Strategies include pre-emptive therapy when viral load increases or CMV-PCR becomes positive on serial monitoring. As cultures for Aspergillus spp are positive only in few cases, serum GM assay is useful for early diagnosis of IPA even before the clinical symptoms and signs becoming obvious. Old age, diabetes, hemodialysis, steroid use and prolonged ICU stay might predispose our patient to develop IPA and CMV pneumonia. Voriconazole was not given for our patient in time, which also highlighted the importance of early diagnosis and therapy.