CYTOMEGALOVIRUS PNEUMONITIS IN A CRITICALLY ILL PATIENT WITH RHEUMATOID ARTHRITIS ON IMMUNOTHERAPY

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Cytomegalovirus (CMV) pneumonitis is an uncommon diagnosis typically seen in patients with immunosuppression. It can range in pathology from minimal interstitial pneumonitis to diffuse alveolar damage. It is associated with high morbidity and mortality in HIV patients and transplant recipients but is rare in patients with autoimmune diseases on immunotherapy. CASE PRESENTATION: A 52 year old female with previous history of rheumatoid arthritis on methotrexate and infliximab for over 1 year was transferred from outside hospital to the ICU after progressive dyspnea and tachypnea with high fever for two weeks that had not been improving on antibiotics. She was intubated for pending respiratory failure and had an urgent bronchoscopy with lavage. Sample from BAL showed histoplasmosis and amphotericin B with broad antibiotics and steroid burst was started. Her course was complicated over the first week of her stay by shock requiring pressor support, AKI, transaminitis, anemia, thrombocytopenia, and difficulty weaning from the ventilator. She was diagnosed with disseminated histoplasmosis. Other labwork for infectious and autoimmune workup at this time had been negative, including histo antigen, blastomyces, toxoplasma, HIV, hepatitis panel, ANA, and ANCA panel. Extubation was attempted on day 12 of her stay but she required reintubation the following day. Ampho B was switched to itraconazole at this time but patient still did not significantly improve after several more days. A surgical lung biopsy revealed CMV with diffuse alveolar damage in addition to histoplasmosis and the patient developed a pneumothorax. Viral load PCR for CMV was 99500 IU/ml. Ganciclovir was started. Her course would be complicated further by A-Fib with RVR and neutropenia, but over the next several weeks her oxygenation and overall clinical condition would slowly improve. She was transferred to LTACH after a 2 month long ICU stay. She was eventually extubated at LTACH and is currently doing well at home following an inpatient rehab stay. DISCUSSION: This patient developed multiple organ failure during her ICU stay and only began to clinically improve following diagnosis and treatment of her CMV infection. She did not respond well to broad spectrum antibiotics or antifungal initially. BAL has poor sensitivity and specificity for CMV and more aggressive diagnostic workup is sometimes indicated. There are no current guidelines for either antiviral prophylaxis or duration of therapy for CMV in setting of autoimmune disorder on immunotherapy. CONCLUSIONS: We strongly suggest that in patients on immunosuppressive therapy with acute respiratory failure who fail to respond to treatment with a recognized pathogen, other pathologies should be considered. Reference #1: Papazian L et al. Cytomegalovirus reactivation in ICU patients. Intensive Care Med. Jan;42(1):28-37. 2016 Reference #2: Travi G et al. Cytomegalovirus pneumonia in hematopoietic stem cell recipients. J Intensive Care Med. Jul-Aug;29(4):200-12. 2014 Reference #3: Lee KY et al. Predictors of Mortality in autoimmune disease patients with concurrent cytomegalovirus infections detected by quantitative real-time PCR. PLoS One. Jul 25;12(7). 2017 DISCLOSURES: No relevant relationships by Clifford Hecht, source=Web Response