The COP Out Diagnosis: A Rare Case of CMV Pneumonitis and COVID19 Organizing Pneumonia

Introduction: Cytomegalovirus (CMV) pneumonitis is well known as a life-threatening condition in immunocompromised risk groups and has been implicated in the development of cryptogenic organizing pneumonia (COP). We present a unique case of CMV pneumonitis confounded by COP related to a recent SARS-Coronavirus 19 (COVID19) infection. It is important for clinicians to recognize underlying red herrings or potential anchoring bias in the differential of COVID19 sequelae including secondary opportunistic infections. Description: A fifty-five year old gentleman presented with fevers, cough, dyspnea, and myalgias for nine days which progressed to acute hypoxemic respiratory failure. Computed tomography (CT) of the chest showed diffuse ground glass airspace disease with hilar lymphadenopathy and left lower basal consolidation (Figure 1). Diagnostic differentials considered included community acquired pneumonia and COVID19 bronchopneumonia. Empiric antibiotics, Anakinra, and systemic steroids were started. Initial microbiologic studies were negative for bacterial, fungal or viral etiologies, as were serologic testing for autoimmune diseases. COVID19 nucleic acid amplification probes were negative on five separate swabs. The patient failed to clinically improve and ultimately was referred for surgical lung biopsy. The biopsy revealed intranuclear viral inclusions and findings of chronic fibrosing interstitial organizing pneumonia with CMV pneumonitis. Serum CMV polymerase chain reaction (PCR) showed a viral load of 2,520 IU/mL and COVID-19 specific serum IgG was later found to be positive. The patient was treated with therapeutic dose of ganciclovir for two weeks and given a longer steroid course for the organizing pneumonia. After a prolonged hospital stay, the patient was discharged home with tapered prednisone and supplemental oxygen. Discussion: The coexistence of COVID19 and CMV pneumonitis has reported to date in one other case to our knowledge (1,3). We hypothesize that COVID19 infection as evidenced by positive IgG could have served as the inciting event leading to the development of organizing pneumonia. Systemic steroids can induce a relative immunosuppressed state which predisposes to opportunistic infections like CMV pneumonitis. Alternatively, CMV can reactivate in critically ill patients (2). Of note, this case demonstrates the perils of confounding diagnoses and anchoring bias as our patient likely failed to respond clinically to systemic steroid therapy for COP while secondarily infected with CMV. This case highlights the need to consider other possible confounders in the diagnostic differential for COVID19 sequalae when patients are not responding adequately to empiric treatment and to evaluate more histopathologic or post-mortem examinations of COVID19 patients.