A young patient with multisystem complications after cytomegalovirus infection
An 18-year-old previously healthy male presented to the clinic with the complaints of sore throat and generalized malaise. The patient denied any history of alcohol or drug use. He denied any history of recurrent infections. The patient had no history of bleeding diathesis. His platelet count was normal. He had a negative rapid monospot and rapid strep antigen test. He recovered from acute illness in 3 days.\nHe noticed dysphagia and paresthesias of both lower extremities and weakness in all extremities (lower > upper, proximal > distal) one day after recovering from sore throat. On neurological examination, patient had bilateral facial nerve palsy and bulbar palsy. Motor strength was grade 1 in lower extremities and grade 2 in upper extremities. Muscle tone of the limbs was decreased. Deep tendon reflexes on the upper limbs were diminished and absent on the lower limbs.\nBlood chemistry was normal, except for total bilirubin of 2.3 mg/dL, alanine transferase and aspartate transferase levels of 87 IU/L and 67 IU/L respectively, indicating hepatitis, which may be due to acute CMV infection. Test for human immunodeficiency virus was negative. His serology was positive for CMV immunoglobulin M (IgM) and Immunoglobulin G (IgG) antibodies. CMV polymerase chain reaction (PCR) was positive with <2000 copies of deoxyribonucleic acid (DNA). Cerebrospinal fluid analysis was done, and it was positive for CMV IgG antibody and increased amount of proteins. He was treated with ganciclovir for acute CMV viremia and received three doses of intravenous immunoglobulin without much response. Patient had diffuse decrease in sensory and motor amplitudes, low normal conduction velocities, prolonged distal motor latencies in the left upper limb, and absent or prolonged F-wave responses on nerve conduction studies with severely decreased recruitment throughout, and a few positive sharp waves and fibrillation potentials on needle electromyography. These findings were most consistent with an acute diffuse neuropathy, most likely acute inflammatory demyelinating polyradiculopathy in early stage.\nDay 4: Patient developed acute respiratory failure and was placed on mechanical ventilator.\nDay 12: He demonstrated a slow and gradual improvement in his strength mostly in upper extremities after starting plasma exchange daily for 5 days.\nDay 15: He was discharged to a rehabilitation facility. He had bifacial weakness; motor strength was 2/5 in lower and 3/5 in upper extremities. Sensations were intact.\nDay 16: He developed acute onset of abdominal pain in left upper quadrant with high grade fever (103.4 F) and was admitted to the hospital. He was found to have dislodged gastrostomy tube, which was replaced by the interventional radiology. After that, the patient had an exploratory laparotomy. He was started on broad-spectrum antibiotics and culture was sent which grew coagulase negative staphylococcus. The patient continued to have high-grade fevers (102.9 F) despite exploratory laparotomy and aggressive wash out. Repeat CMV PCR was negative. Serum IgG ganglioside GQ1b antibody was <1:100 titers.\nDay 21: Repeat computed tomography (CT) abdomen showed modest sized splenic infarct [Figures and ] and prominent colitis. Patient had a small hypodense focus in the periphery of the spleen on the follow-up CT abdomen on day 25 and day 32, which was consistent with evolution of splenic infarct.\nDay 42: CT abdomen on the day of discharge showed decrease in the size of splenic infarct. Patient's condition was improved gradually and ultimately he was discharged to a rehabilitation facility.