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Title:
Swollen Brain & Bleeding Guts – Key to an Underlying Systemic Infection
Preferred Mode of Presentation: Oral Author: Dr. Swarnadeep Mani¹; Dr. Debajyoti Majumdar2; Dr. Dolonchampa Modak3 Institutional Affiliations: 1 – Junior Resident* 2 – RMO cum Clinical Tutor* 3 – Associate Professor* *Department of Tropical Medicine, School of Tropical Medicine, Kolkata Postal Address for Correspondence with Pin code: 27/1A, M. G. Road, Tollygunj Karunamoyee, Kolkata – 700082 Mobile No of Corresponding author: 8240363530 Mail ID of Corresponding author: swarnadeep.mani11@gmail.com
Abstract
Introduction: Cytomegalovirus infection in immunocompromised host can affect GI tract(esophagitis, colitis), liver(hepatitis), bone marrow(cytopenias), CNS(encephalitis, meningitis, retinitis) , peripheral nerves(radiculopathy), lungs(penumonia) with retinitis being the most common manifestation in HIV patients. Here we are reporting a rare case of CMV infection in HIV patient who presented with encephalitis and thrombocytopenia without any evidence of retinitis. Case details: A 60 year old non-diabetic non-hypertensive female was admitted in hematology unit of an outside hospital with chief complaints of hematemesis for 4 days a/w echhymotic patches all over the body. There was no history of fever, loose stool with blood, pain abdomen. No organomegaly, lymphadenopathy or sternal tenderness. Routine examination showed normocytic normochromic anemia & severe thrombocytopenia (<5000 cells/cumm). Coagulation profile was normal. USG was non-contributory. Other investigations were within normal limits. She was provisionally diagnosed as a case of thrombocytopenia probably ITP and started on glucocorticoids. Meanwhile, she was investigated for autoimmune and infective causes of ITP and the patient turned out to be positive for HIV-1 antibody. So, she was referred to School of Tropical Medicine for further management. During her admission, she had echhymotic patches over her body and multiple papular lesions over her face. HbsAg, anti HCV were non-reactive; MPDA, Dengue IgM were non-reactive; Her initial CD4 count was 34 cells/cumm. Chest Xray was normal. Indirect ophthalmoloscopy did not show signs of any opportunistic infections. Biopsy from skin lesions were non-contributory. Upper GI endoscopy was done to investigate the cause of GI bleed which showed esophageal candidiasis and erosive gastritis. Biopsy from gastric mucosa sent for HPE showed inflammation and ulceration, with neutrophilic infiltration in lamina propria. In view of bicytopenia and low CD4 count, Bone Marrow aspiration and biopsy was done to rule out Tuberculosis, hematological disorder or any deep seated fungal infection. But it showed normal maturation of all 3 cell lines. No atypical cells were seen. No evidence of any Infective etiology could be found. During her stay at hospital, the patient became drowsy and had one episode of generalized seizure. She was managed with anti-epileptics. Lumbar puncture done next day opening pressure was normal, appearance of CSF was clear. CSF study showed cell count 3 cells/cumm (lymphocyte only), slightly elevated protein (75 mg/dl), normal sugar (60 mg/dl) (CBG-96 mg/dl). MRI brain showed nonspecific white matter T2 hyperintensity with periventricular contrast enhancement. CSF sent for AES panel was negative. Although no evidence of retinitis or GI pathology could be found, Considering the thrombocytopenia and encephalopathy like features the likelihood of CMV infection was to be ruled out. Blood was sent for CMV DNA PCR and results were positive at high titre (86000 copies/ml). CSF was also sent for CMV DNA PCR and it also came out to be Positive (63000 copies/ml). The patient was diagnosed to be a case of CMV encephalitis with thrombocytopenia and esophageal candidiasis in immunocompromised state due to HIV. She was started on IV Ganciclovir 5mg/kg 12 hourly , oral Fluconazole 200mg/day and Cotrimoxazole DS 1 tab daily. After 2 weeks of therapy, her platelet count gradually increased (70000 cells/cumm) and her neurological function improved. After 3rd week of IV Ganciclovir, she was shifted to oral Valgancyclovir 900 mg/day, fluconazole was stopped and discharged for follow-up after 1 week for initiation of ART. Conclusion: CMV can have diverse manifestations in PLHIV with very low CD4 count (<50cells/cumm) and merely ophthalmological or endoscopic examination is insufficient to rule out the possibility of such illness. Keywords: Cytomegalovirus, HIV, Encephalitis, Thrombocytopenia
