405: A CASE OF CMV POLYRADICULOMYELITIS IN AN IMMUNOCOMPETENT PATIENT

Abstract

Introduction: Cytomegalovirus (CMV) is a common virus. It can reside latent after primary infection and be reactivated at any time. Reactivation is most common in immunocompromised patients, though it can still occur in immunocompetent patients, often in the ICU in the setting of critical illness and typically limited to pneumonia or viremia. Neurologic infections are less common and primarily in immunocompromised patients. The following case is a unique presentation of polyradiculomyelitis in an immunocompetent patient, caused by CMV reactivation. Description: A 77-year-old male with hypertension was admitted for dyspnea and encephalopathy and treated for pneumonia. Lumbar puncture and head MRI were unremarkable. After 17 days, he was transferred to our institution and required mechanical ventilation for respiratory failure due to mucus plugging. After extubation two days later, he was noted to have new bilateral lower extremity flaccid paralysis and bowel incontinence. MRI revealed transverse myelitis from T6 through the conus medullaris, neuritis of all lumbar nerve roots, and significant cord edema. Repeat lumbar puncture was remarkable for CSF pleocytosis and positive CMV. Serum IgG was also positive for CMV. Findings were felt to be inconsistent with alternative diagnoses, such as multiple sclerosis, neuromyelitis optica, acute inflammatory demyelinating polyneuropathy, or Guillain-Barre. Ganciclovir, foscarnet, and dexamethasone were initiated. Patient ultimately required re-intubation and tracheostomy for inability to clear secretions. There was no improvement in his neurologic status by time of discharge to a long-term acute care facility. Discussion: Neurologic manifestations (meningitis, encephalitis, etc.) from CMV are usually only seen in immunocompromised patients. CMV causing a polyradiculomyelitis (besides the ascending paralysis associated with Guillain-Barre) is rare, especially so in this patient with a normal immune status. This case is uniquely relevant to the intensivist. The patient developed symptoms weeks after admission, indicating that it was likely his critical illness that put him at high risk for reactivation of a latent infection. Additionally, diffuse transverse myelitis placed him at high risk for respiratory compromise and irreversible respiratory failure.