Suspected CMV Associated Myelitis in Immunocompetent Adult without Supporting PCR from the CSF

Case Report

Austin J Clin Neurol 2015;2(2): 1026.

Suspected CMV Associated Myelitis in Immunocompetent Adult without Supporting PCR from the CSF

Meir Kestenbaum>1,2, Eitan Auriel E1,2, Haim Perloock2 and Arnon Karni1,2*

1Department of Neurology, Tel Aviv Sourasky Medical Center, Israel

2Sackler’s Medical School, Tel Aviv University, Israel

*Corresponding author: Arnon Karni, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel

Received: December 18, 2014; Accepted: March 18, 2015; Published: April 08,2015


The occurrence of Cytomegalovirus (CMV) myelitis among immunocompetent patients is extremely uncommon. We present a 53 year old immunocompetent female with myelitis that was associated with infection of CMV that was detected by positive Immunoglobulin M (IgM) antibodies, seroconversion of Immunoglobulin G (IgG) antibodies with low avidity index, but the polymerase chain reaction (PCR) test for CMV in the cerebrospinal fluid (CSF) was negative. We suggest here, that the absence of supporting PCR from CSF or blood CMV antigen should not exclude the diagnosis, especially in the immunocompetent patients.

Keywords: Cytomegalovirus; Cerebrospinal fluid; Computerized tomography; Polymerase chain reaction

Case Presentation

A 53 year old female with no previous significant medical history was hospitalized due to progressive paraparesis. One week prior to her admission she had mild lower back pain with no radiating pain and no neurological impairment. After 5 days she developed a progressive paraparesis combined with lower limbs numbness and urinary incontinence. The patients reported that 2 weeks prior to the onset of symptoms 3 members of the patient’s close family had upper respiratory infection (URI) with positive serology for CMV. The patient had denied any URI symptoms. Neurological exam on admission revealed spastic paraparesis with bilateral extensor plantar response and thoracic (T) sensory level at T8. One day following admission the patient deteriorated and became paraplegic. Laboratory blood tests demonstrated normal complete blood count, C-reactive protein and chemistry with the exception of mild elevation of liver enzymes (alanine aminotransferase, aspartate aminotransferase and Gamma-glutamyl transferase). Computerized tomography (CT) with contrast revealed no significant findings. Magnetic resonance imaging (MRI)of the entire neuro-axis including the T2 weighted images and fluid-attenuated inversion recovery (FLAIR) sequences demonstrated two elongated intramedullary hyperintense lesions at the levels of T5-8 and T9-12 with mild swelling of the cord and enhancement following injection of gadolinium in T1 weighted images (Figure). Lumbar puncture showed 13white blood cells/μl with lymphocyte predominance, mild elevation of protein (61 mg/dl), normal glucose with no oligoclonal bands. Gram stain and cultures were negative. Serum IgG for CMV was 8 AU/ml and IgM was found within borderline values. No detection of CMV antigen was found in the blood. PCR for the CMV – DNA in the CSF was negative. Extensive serology studies for the agents: echo virus, coxsackie virus, herpes simplex, varicella zoster, HIV, mycoplasma pneumonae, toxoplasma gondii, borrelia burgdorferi, brucella abortus, brucella melitensis, HTLV 1, rickettsia conorii, bartonella henselae and VDRL were all negative. Serology studies for autoimmune markers including: antinuclear antibody (ANA), complement component 3 (C3), C4, perinuclear Anti-Neutrophil Cytoplasmic Antibodies (p-ANCA), cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA), Anti-Sjögren’s-syndrome-related antigen Antibodies (SSAAb), anti SSBAb, angiotensin-converting enzyme (ACE)and anti aquaporin 4 Ab were all negative. Chest CT scan and visual evoked potential studies were normal.

At the beginning of the admission the patient was treated with intravenous (IV) ganciclovir at a dose of 300 mg twice a day and oral course of doxycycline 100 mg X2 / day. These therapies were terminated after 5 days on the account of the negative results for CMV-DNA PCR from CSF, CMV antigen in the serum and serology for mycoplasma. She was also treated with IV methylprednisolone (1000 mg) for 3days with tapering down as a protocol for transverse myelitis. Although the patient had no visual impairments and visual evoked potential study was normal a plasma exchange course of 7 treatments on alternating days was initiated for the possible diagnosis of neuromyelitis optica that was raised on the account of the long intramedullary lesions as well as the rapidly progressing myelitis. Following the deterioration during the first two days of hospitalization in which the patient became paraplegic, she began to improve gradually from the fifth day of admission and was discharged after 17 days with only mild paraparesis, lower body hypoesthesia and incontinence. One month following discharge the patient underwent another MRI of the neuroaxis that showed significant improvement in the severity of the intramedullary lesions and in the swelling of the spine as well (Figure). A second blood serology for CMV revealed positive IgM and IgG antibodies with constant elevation of IgG titer in serial tests (24 AU/ml) although the CMV antigen remained negative. CMV antibodies avidity in the blood was found to be low. During the following year the patient underwent physical therapy and rehabilitation and improved gradually with complete resolution of her symptoms. On her last examination she was neurologically intact.

Citation: Kestenbaum M, Eitan Auriel E, Perloock H and Karni A. Suspected CMV Associated Myelitis in Immunocompetent Adult without Supporting PCR from the CSF. Austin J Clin Neurol 2015;2(2): 1026. ISSN : 2381-9154