G415(P) Cytomegalovirus infection presenting as recurrent fever in a child receiving standard chemotherapy for acute lymphoblastic leukaemia

Abstract

<h3>Introduction</h3> Infection presenting with fever is a common cause for hospital admission of immunocompromised children. Initial management is aimed at the treatment and identification of bacterial and fungal infection. Cytomegalovirus (CMV) is well recognised as causing increased morbidity and mortality in immunocompromised children who have undergone stem cell transplants but less so in children receiving standard chemotherapy in acute lymphoblastic leukaemia. <h3>Case description</h3> Our patient is a 7 year old girl receiving standard chemotherapy for acute lymphoblastic leukaemia. Post induction she was admitted with significant fever but no other clinical signs or symptoms. She was not neutropenic, CRP was unremarkable and cultures negative. A chest X-ray showed right middle lobe changes and CT chest showed consolidation and atelectasis but no ground glass appearance or nodules. Candida PCR and beta-D-glucan test were negative. She received a course of empiric antibiotics, including macrolides, and antifungal treatment. Her fever settled. Following cessation of treatment she was readmitted with fever and a dry cough and intravenous antibiotic and antifungal therapy was recommenced. Repeat investigative workup was unremarkable. She settled. A further brief admission with fever settled without intervention following which she was readmitted for the fourth time with fever and cough. She became unwell, developing an oxygen requirement with respiratory signs on chest auscultation. Blood viral PCRs were sent. CMV PCR was significantly elevated at 142,000 copies/ml. BAL fluid was CMV positive and negative for fungi. Intravenous foscarnet was added to the treatment regime. She improved with this and empirical antifungal treatment. <h3>Results and conclusion</h3> This patient presented with recurrent fevers resulting in prolonged admissions impacting on quality of life and interruption of treatment. No other positive pathogens for the fever were identified apart from CMV. A literature review confirms that CMV is an opportunistic infection that can cause serious, sometimes life-threatening, illness even during conventional anticancer infection due to profound immunosuppression. This is less recognised in clinical practice. We would highlight the importance of considering CMV infection in cases of recurrent and prolonged fever in these children.