CMV Encephalitis/Radiculitis: The Difficulty in Diagnosing in an Intubated Patient

Area of Science:

• Infectious Diseases
• Neurology
• Critical Care Medicine

Background:

• Cytomegalovirus (CMV) can cause severe disease in profoundly immunocompromised individuals.
• Diagnosis of CMV central nervous system (CNS) involvement relies on identifying CMV in cerebrospinal fluid (CSF).
• Prompt antiviral therapy is essential for managing CMV infections, though outcomes can be poor.

Observation:

• A patient with newly diagnosed Acquired Immunodeficiency Syndrome (AIDS) and Pneumocystis jiroveci pneumonia presented with prolonged fever and encephalopathy.
• Despite extensive workup and treatment for 6 weeks, the patient's encephalopathic state persisted.
• The patient was ultimately diagnosed with Cytomegalovirus (CMV) encephalitis and radiculitis, with limited clinical improvement.

Findings:

• This case illustrates an uncommon presentation of CMV encephalitis/radiculitis occurring more than a month into hospitalization.
• The case underscores the challenges in diagnosing severe AIDS-related complications, such as CMV encephalitis, in the current era of highly active antiretroviral therapy (HAART).
• Evaluating altered mental status and weakness in intubated, sedated patients poses significant diagnostic difficulties.

Implications:

• Early consideration of lumbar puncture (LP) is recommended for immunosuppressed patients on mechanical ventilation presenting with unexplained fever and altered mental status.
• This case emphasizes the importance of maintaining a high index of suspicion for opportunistic infections like CMV encephalitis in severely immunocompromised patients, even with advanced therapies.
• Improved diagnostic strategies and timely intervention are critical for improving outcomes in patients with CMV CNS infections.