Congenital Cytomegalovirus Presenting with Macrocephaly and Intracranial Abscess: A Case Report

Congenital cytomegalovirus (cCMV) infection is a leading cause of neurologic disability in infants, often presenting with microcephaly, seizures, and sensorineural hearing loss. However, atypical manifestations such as macrocephaly and intracranial abscess are extremely rare. We report a case of an infant presenting with progressive macrocephaly, with intracranial abscess and obstructive hydrocephalus. She had a history of prematurity and neonatal sepsis. Neuroimaging revealed a rim-enhancing lesion at the quadrigeminal cistern and aqueductal stenosis. Cerebrospinal fluid (CSF) analysis from ventricular tap showed signs of ventriculitis, and both serum and CSF tested positive for CMV IgG and IgM, associated with a high viral load. Antiviral and antibiotic therapy led to resolution of the abscess and ventriculitis. A ventriculoperitoneal shunt was subsequently placed. This case illustrates a rare neurological complication of cCMV presenting with an intracranial abscess and hydrocephalus in an immunocompetent infant. It highlights the wide spectrum of cCMV manifestations and the challenges of diagnosis in settings without routine CMV screening. Early recognition and timely intervention are critical in improving outcomes, especially in low- and middle-income countries where systematic CMV testing is lacking.