ZNFX1 deficiency presenting as recurrent HLH triggered by CMV infection

Interferons (IFNs) are essential cytokines in host defense, particularly against viral pathogens. Dysregulation of IFN signaling can result in increased susceptibility to viral infections, systemic inflammation. We report a 6-month-old male who presented with hemophagocytic lymphohistiocytosis (HLH) triggered by cytomegalovirus (CMV) infection. He was admitted to the Pediatric Intensive Care Unit due to fever and respiratory distress. Laboratory findings revealed pancytopenia, elevated inflammatory markers, and laboratory markers suggestive of HLH. Whole-exome sequencing revealed a novel homozygous nonsense variant in ZNFX1 (c.1928G>A, p.Trp643X). During subsequent hospitalization, he developed CMV reactivation, gastrointestinal symptoms, neurologic deterioration, and multiorgan dysfunction. Despite intensive supportive care and immunomodulation with anakinra and corticosteroids, the patient progressed to irreversible organ failure and died from respiratory failure. This case expands the clinical and genetic spectrum of ZNFX1 deficiency and highlights the importance of considering monogenic interferonopathies in children with severe viral infections, HLH, and unexplained systemic inflammation.