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Abstract：
Background Cytomegalovirus (CMV) reactivation may occur as the shedding of the virus from various body sites or could represent an active disease that might be fatal if untreated. Distinguishing between the two states may prove very difficult. The role of the CMV disease in patients with hematological malignancies or transplant patients is more defined than that in other immunocompromised patients where neither anti-CMV prophylaxis is used nor plasma CMV levels are monitored. Here, we try to examine cases with CMV viremia in the latter group of patients in an attempt to make a distinction between CMV infection and disease to determine which patients would benefit from treatment. Methods Elderly patients, patients with rheumatological disorders, and patients with inflammatory bowel disease (IBD) and with clinical suspicion of CMV disease who were referred to the infectious diseases service at Sultan Qaboos University Hospital were examined from 1 January 2018 to 31 January 2023. We added a patient we found in our referral log book from 2012. Clinical, epidemiological, and laboratory data were retrieved from the hospital information system. Plasma CMV levels and CMV body fluid levels including pulmonary samples obtained from bronchoalveolar lavage (BAL) in suspected cases of CMV pneumonitis and gastrointestinal (GI) CMV levels obtained from stool and gastrointestinal tissue biopsies in suspected cases of gastrointestinal CMV disease were collected. COBAS® AmpliPrep/COBAS® TaqMan®assay (Roche Molecular Systems, Inc., Branchburg, NJ) was used to measure CMV copies per milliliter. Results A total of 28 patients were considered to have CMV disease, 12 of whom were elderly (≥60 years) and the rest were young and middle aged (Y/M). The most common comorbidities of the elderly included chronic kidney disease (CKD), hypertension (HTN), and diabetes mellitus (DM). In the Y/M group, seven patients had systemic lupus erythematosus (SLE), one had antineutrophil cytoplasmic antibody (ANCA) associated vasculitis, four patients had IBD, two had IBD plus primary immunodeficiencies (one patient had agammaglobulinemia and one had combined deficiencies), and one patient had combined immunodeficiency. CKD was a common finding in the SLE patients. Diarrhea was the most common CMV presentation occurring in 19 patients (67.9%), being bloody in 10 patients. Four patients had pulmonary presentations, and four had hematological presentations in the form of anemia or pancytopenia. Nineteen patients were given CMV antiviral treatment, and one patient received it during the first episode but not in the second episode. Twenty-eight-day mortality in the treated group was 20% versus 55.5% in the untreated group. The majority of the deaths occurred in the SLE and elderly patients. Thrombocytopenia occurred in 60.7%, 70.6% of whom died signaling a potential predictive role for thrombocytopenia in early empirical CMV antiviral treatment and in prognosis. Conclusion The difficulty in distinguishing CMV infection from CMV disease remains a concern in the elderly and SLE patients. In our small study, there was a survival benefit in early screening for CMV and initiating preemptive CMV antiviral therapy in these two groups even before CMV disease is proven. This urgency was not observed for patients with IBD or primary immunodeficiencies. A major common factor for CMV disease was CKD, whereas thrombocytopenia was an indicator of disease and prognosis.
摘要：
背景巨细胞病毒（CMV）的再激活可能是由于病毒从各个身体部位脱落而发生的，或者可能代表一种活动性疾病，如果不治疗，可能是致命的。区分这两种状态可能非常困难。CMV疾病在血液恶性肿瘤患者或移植患者中的作用比在其他既不使用抗CMV预防也不监测血浆CMV水平的免疫受损患者中的作用更明确。这里,我们尝试检查后一组患者中的CMV病毒血症病例,试图区分CMV感染和疾病,以确定哪些患者将从治疗中获益.方法老年患者,风湿病患者，在2018年1月1日至2023年1月31日期间,我们对转诊至苏丹卡布斯大学医院传染病服务机构的炎症性肠病(IBD)和临床怀疑CMV疾病患者进行了检查.我们在2012年的转诊日志中添加了一名患者。临床,流行病学,和实验室数据从医院信息系统检索。收集了疑似CMV肺炎病例中的血浆CMV水平和CMV体液水平，包括从支气管肺泡灌洗（BAL）获得的肺样本，以及在疑似胃肠道CMV疾病病例中从粪便和胃肠道组织活检获得的胃肠道（GI）CMV水平。COBAS®AmpliPrep/COBAS®TaqMan®测定(罗氏分子系统，Inc.,布兰奇堡,NJ)用于测量每毫升CMV拷贝。结果共28例患者被认为患有CMV疾病,其中12人为老年人（≥60岁），其余为中青年（Y/M）。老年人最常见的合并症包括慢性肾脏病（CKD），高血压（HTN），糖尿病（DM）。在Y/M组中，7例患者患有系统性红斑狼疮（SLE），其中一人患有抗中性粒细胞胞浆抗体（ANCA）相关性血管炎，四名患者患有IBD，两名患者患有IBD加原发性免疫缺陷（一名患者患有丙种球蛋白血症，一名患者患有联合缺陷），1例患者合并免疫缺陷。CKD是SLE患者的常见发现。腹泻是19例患者中最常见的CMV表现（67.9％），10名患者流血。四名患者有肺部表现，其中4例有贫血或全血细胞减少症的血液学表现。19例患者给予CMV抗病毒治疗,一名患者在第一集中接受了它，但在第二集中没有接受。治疗组中的28天死亡率为20%,而未治疗组中为55.5%。大多数死亡发生在SLE和老年患者中。血小板减少发生率为60.7%,其中70.6％的人死亡信号在早期经验性CMV抗病毒治疗和预后中对血小板减少症具有潜在的预测作用。结论老年人和SLE患者难以区分CMV感染和CMV疾病仍然是一个问题。在我们的小书房里，即使在CMV疾病被证实之前,这两组在CMV早期筛查和开始先发制人的CMV抗病毒治疗中也有生存获益.对于患有IBD或原发性免疫缺陷的患者没有观察到这种紧迫性。CMV疾病的主要常见因素是CKD，而血小板减少是疾病和预后的指标。
