SHM Converge Scientific Abstract ePoster Gallery-It Can Be Tricky to See-Mv: A Case of Cytomegalovirus Reactivation in High Dose Steroid Use for Pneumocystis Pneumonia

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This case describes a 68-year-old man with a history of cryptogenic cirrhosis and hepatocellular carcinoma, status post liver transplant from a CMV-positive donor, who was transferred with severe hypoxic respiratory failure. Before transfer, bronchoalveolar lavage had shown Pneumocystis jirovecii, and his serum CMV had been undetectable after valganciclovir treatment. He was treated with high-dose steroids and anti-PJP therapy, initially improved, and was extubated. However, he later worsened with recurrent respiratory failure and ARDS, requiring re-intubation and paralysis. Despite broad-spectrum antibiotics and supportive care, he did not improve. CMV testing was delayed until day 18 of intubation, when serum CMV returned markedly elevated at 260,000 IU/mL. Valganciclovir was restarted and steroids were tapered, but his prolonged critical illness led to comfort care and death.<br /><br />The case was judged to represent a highly likely diagnostic error. Key issues included premature focus on the recent CMV treatment, failure to broaden the differential beyond Pneumocystis pneumonia in an immunocompromised transplant patient, and failure to recognize CMV reactivation as a possible complication of high-dose steroids. The team also delayed ordering testing to evaluate for CMV pneumonitis.<br /><br />The discussion emphasizes that CMV and PJP frequently co-occur in solid organ transplant recipients and can have overlapping, atypical imaging findings that obscure diagnosis. A prior CMV episode does not rule out recurrence or progression to disseminated disease. The authors recommend diagnostic “pauses” to reconsider the differential at the first sign of worsening and again when patients fail to respond to appropriate therapy, along with re-consulting subspecialists after decompensation.

Asset Subtitle

Angela Alday

Meta Tag

Author List A Shams Helminski, Angela Alday, James Anstey, Mengyu Zhou

Category Clinical Vignettes

Concept Cytomegalovirus Reactivation

Concept Immunocompromised State

Concept Pneumocystis jirovecii pneumonia

Concept Differential Diagnosis

Concept Varicella-Zoster Virus Pneumonitis

Distinguished Non-Finalist

Presenter Organization Division of Hospital Medicine, Oregon Health & Science University School of Medicine

Presenting Author Angela Alday

Track Adult

Keywords

cytomegalovirus

Pneumocystis jirovecii

liver transplant

respiratory failure

acute respiratory distress syndrome

immunocompromised

diagnostic error

steroids

CMV reactivation

CMV pneumonitis

Cytomegalovirus Reactivation

Immunocompromised State

Pneumocystis jirovecii pneumonia

Differential Diagnosis

Varicella-Zoster Virus Pneumonitis