Background/Purpose: CMV is a ubiquitous herpes virus associated
with significant immunosuppression. Immunosuppressive
treatments and ageing is well known risk factors for CMV reactivation. 
There are only a few case series about CMV disease in patients with
rheumatologic diagnosis. In this report we present descriptive data of our
rheumatic patients with CMV disease.

Methods: Database of our university hospital between
2000 and 2014 years was searched for CMV disease. Totally 34 (Female/Male:
25/9) patients with Rheumatic diseases were included into the further analysis.
Patients’ demographic data like age and gender, rheumatologic diagnoses,
receiving immunosuppressive drugs at the admission, need of intensive care unit
admission, clinical presentation type and outcomes were recorded. Confirmation
of CMV disease was mainly based on CMV viral load in blood samples detected by
molecular techniques (PCR), pathological examination of biopsy specimens, eye fundoscopic evaluation and radiologic imaging.

Results: The mean age was 50.4±3.08 years. Most of the patients
have vasculitis (44%). Ten patients (29%) had Systemic Lupus Erythematosus, and
5 patients (15%) had Rheumatoid arthritis. Other diagnoses were Still’s
disease, dermatomyositis and anti-synthetase
syndrome. Patients are grouped according to their co-morbidities and 9 of them
(27%) had a history of hypertension while 7 (21%) had diabetes and 8 (24%) had
chronic renal disease. 5 patients were consuming tobacco at the time of appeal.
Median dose of steroid treatment was 40 mg/day (0-60 mg). 13 (38%) were on
pulse therapy. Except for one patient, all of the patients were using steroids
at the time of CMV disease. 29 (85%) patients were using any additional
immunosuppressive agent. Cyclophosphamide was the
mostly used immunosuppressive agent (44%). Five patients were on anti-TNF
therapy (infliximab:2, etanercept:
2, adalimumab: 1) and two patients were using rituximab. Other therapeutic agents were MMF (n=4), azathioprine (n=5), methotrexate
(n=2) and leflunomide (n=1). Median time between the diagnosis of rheumatologic
disease and CMV re-activation was 2.5 years (0-30 years), while mean time was
6.4±1.4 years. 26 (76%) patients required intensive care unit management. 19
(56%) of patients had died. There was no difference regarding between concomitant
rheumatic diseases (p=0.66). Majority of patients were presented with pneumonia
(59%). 5 patients (15%) had GIS involvement, 2 (%6) patients had retinitis, 1
patient had pneumonia and GIS involvement. In 6 patients (18%) the only symptom
was high fever. Mortality was significantly high in patients with pneumonia (71%)
and gastrointestinal involvement (67%), p=0.01).

Conclusion: In patients with rheumatic disease, CMV
infections are very rare but have a high mortality rate. Corticosteroids, cyclophosphamide and biologic agents were the mostly used
immunosuppressive agents in our patients. CMV disease should be kept in mind
especially in rheumatic patients with respiratory failure and gastrointestinal
bleeding.

Reference:

1.      
Kraft CS, Armstrong WS, Caliendo AM. Interpreting quantitative cytomegalovirus DNA testing: understanding the laboratory perspective. Clin Infect Dis. 2012 Jun;54(12):1793-7.