Clinical Pictures of 28 Cases with Pathology-proven Cytomegalovirus Pneumonia

Abstract

Background: The purpose of this study was to review cases of biopsy-proven cytomegalovirus (CMV) pneumonia in a tertiary medical center in Taiwan. Patients and Methods: From January 1995 to December 2005, 28 patients with biopsyproven CMV pneumonia were included in this study. The following data were recorded: demographics, clinical manifestations, radiographic and laboratory findings, histopathology, treatment regimens, and outcome. Results: The study population consisted of 21 male and 7 female patients, with a mean age of 38.9±13.24 years. All were immunocompromised hosts, including 11 patients with acquired immunodeficiency syndrome (AIDS) and 9 who had undergone hematopoietic stem cell transplants (HSCT). The most frequent clinical manifestations were fever (67.9%), cough (57.1%), and dyspnea (89.3%). Elevated levels of C-reactive protein and lactate dehydrogenase were observed in the majority of patients. The ratio of arterial oxygen pressure over inspired oxygen (PaO2/FiO2) at diagnosis was 71.9±27.6 mm Hg. The mean CD4 lymphocyte count was 55±61.2 per μL in the AIDS patients. CMV IgM antibody titers were available in 11 cases only, and were all negative. The predominant high resolution computed tomography findings included ground-glass opacity (53.6%) and air-space consolidation (53.6%). Major histological findings associated with CMV pneumonia were fibrosis (39.3%) and Pneumocystis jirovecii pneumonia (PCP) (25%). Twenty (71.4%) patients developed respiratory failure, which occurred in 54.5% and 77.8% of the AIDS and post-HSCT groups, respectively (p=0.28). Nearly all of the patients (88.9%) in the post-HSCT group received combination therapy with anti-viral agents and anti- CMV immunoglobulin (CMVIG). In contrast, all of the patients with AIDS received anti-viral agents only. Treatment for 60% of patients was modified after biopsy. The 28-day survival rate was 53.6%, which was higher in AIDS patients than in post-HSCT patients (81.8% vs. 33.3%, p=0.028). Conclusions: CMV pneumonia still carries a high risk of mortality in immuno-compromised patients in Taiwan. Our data suggest that no clinical, laboratory, or radiographic features are reliable indicators for diagnosis, and invasive biopsy procedures are often required for definitive diagnosis. Post-HSCT CMV pneumonia is associated with a higher mortality than AIDS.