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Cytomegalovirus myelitis in perinatally acquired HIV
1Centre of Paediatrics, Johann Wolfgang Goethe University Hospital, 6000 Frankfurt/Main, Germany.
Abstract:
A 7 year old child perinatally infected with HIV who died from progressive muscular paralysis and central nervous respiratory failure is described. Cytomegalovirus (CMV) prophylaxis with a special intravenous CMV hyper-immunoglobulin had been successfully conducted for more than four years. Macroscopic and microscopic immunohistochemical examination of the spinal cord revealed a diffuse CMV infiltration of the entire myelon. CMV infected cells were identified as astrocytes, oligodendrocytes, neurons, macrophages, ependymal, endothelial, and Schwann cells. Other organs had no signs of CMV infection. Central nervous spinal CMV infection was most probably due to insufficient penetration of the blood-brain barrier by the CMV hyper-immunoglobulin. In suspicious cases early spinal magnetic resonance imaging (1.5 tesla) combined with an examination of urine and cerebrospinal fluid for CMV is recommended.
Insights
A child with HIV experienced fatal muscular paralysis due to cytomegalovirus (CMV) spinal cord infection, despite prophylaxis. This highlights challenges in preventing central nervous system CMV disease in immunocompromised individuals.
Area of Science:
- Neurology
- Infectious Diseases
- Immunology
Background:
- Perinatal HIV infection poses significant risks for opportunistic infections affecting the central nervous system.
- Cytomegalovirus (CMV) is a common opportunistic pathogen in immunocompromised individuals, including those with HIV.
- Prophylaxis strategies aim to prevent CMV disease, but their efficacy in penetrating the blood-brain barrier can be variable.
Observation:
- A 7-year-old child with perinatal HIV infection developed progressive muscular paralysis and respiratory failure.
- Despite over four years of successful intravenous CMV hyper-immunoglobulin prophylaxis, the child succumbed to the illness.
- Post-mortem examination revealed diffuse CMV infiltration of the spinal cord, affecting various cell types including neurons and glial cells.
Findings:
- Cytomegalovirus (CMV) infected a wide range of cells within the spinal cord, including astrocytes, oligodendrocytes, neurons, macrophages, ependymal cells, endothelial cells, and Schwann cells.
- No signs of CMV infection were detected in other organs, indicating a localized central nervous system event.
- The CMV hyper-immunoglobulin prophylaxis likely failed to adequately penetrate the blood-brain barrier, allowing for localized CMV replication in the spinal cord.
Implications:
- Central nervous system cytomegalovirus (CMV) infection can occur even with systemic prophylaxis, particularly if the blood-brain barrier limits drug penetration.
- Early diagnosis of spinal CMV infection is crucial and may benefit from magnetic resonance imaging (MRI) and analysis of cerebrospinal fluid (CSF).
- Further research into strategies for enhancing CMV drug delivery across the blood-brain barrier is warranted for effective management of neurological complications in immunocompromised patients.