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CMV Pneumonitis in a Neonate

CMV Pneumonitis in a Neonate. Mimi Emig, MD Spectrum Health Infectious Diseases Grand Rapids, MI. HPI. 3 month old admitted with 2d cough + decreased po intake Born at 33 weeks EGA d/t maternal eclampsia + seizure 12 days in newborn nursery. HPI, continued.

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CMV Pneumonitis in a Neonate

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  1. CMV Pneumonitis in a Neonate Mimi Emig, MD Spectrum Health Infectious Diseases Grand Rapids, MI

  2. HPI • 3 month old admitted with 2d cough + decreased po intake • Born at 33 weeks EGA d/t maternal eclampsia + seizure • 12 days in newborn nursery

  3. HPI, continued • Brought to primary care with decreased po intake, cough for 2 days • Usu feeds 4-6 oz; now < 1 oz; decreased wet diapers • Sent to ED- on arrival, dusky, poor capillary refill, desaturating

  4. Social History • Lives with mom & 17 yo brother • Mom is 35 yo, in stable relationship for 5 years

  5. Exam • T 38; SBP 65; P 156; P ox 95% on 1L NC • Weight 5kg • Subcostal retractions; tachypneic

  6. Initial Labs / Studies • WBC 9.3 (36N, 59L) Hb 10.9 Plt 436K • AST 79, ALT 59 • BC neg • CSF 3WBC; cx neg • CXR bilateral patchy perihilar infiltrates, bilateral lower lobe alveolar infiltrates

  7. Hospital Course • HD 3- increased respiratory distress, transferred to ICU • Intubated • Blind BAL sent • Progressive respiratory failure, requiring high frequency oscillating jet ventilation

  8. Hospital day 7 • BAL grew CMV- pediatric ID consulted • Added IV ganciclovir • Bactrim + steroids started pending PCP Ag • Immune w/u sent

  9. HD 10 • Bactrim & steroids stopped • No substantial improvement in respiratory status- still requiring HFOJV

  10. HD 13 • CD4 = 426 (27%) • HIV DNA qualitative positive • Increased ganciclovir to 6mg/kg q12hr • Started preventive TMP/SMX

  11. Maternal Hx • Last tested negative during blood donation 5 yr ago • Never tested for HIV during pregnancy • In “stable relationship”, but partner married to another woman • Maternal testing- CD4 = 61

  12. Testing of Neonate • VL 1.77 million (log 6.25) • HLA B*5701 negative • No significant resistance mutations

  13. Clinical Issues • 1) Pneumonitis not improving; all other testing (PCP, Crypto, fungal, AFB) negative. What would you do next? (now HD 15) • 2) When would you start antiretrovirals?

  14. Hospital Course • HD 15- added high-dose Bactrim + steroids • HD 18- off HFOJV, on conventional ventilator • Transaminases rising- 500-600 • HD18- started stavudine / lamivudine / Kaletra • HD 22- extubated

  15. Hospital Course • Remained O2 dependent • Completed 21 d high-dose Bactrim + steroids; changed to secondary prophylaxis • Tolerated antiretrovirals well, LFT’s came down to nl • After 2 weeks tx: • Viral level 76,000 (prev 1.77 million) • CD4 1207 (previously 426)

  16. Hospital Course • Increasing FiO2, low-grade fevers • HD 42- bronchoscopy + PCP • Retreated with high-dose Bactrim + steroids- weaned off O2 • Discharged home after 72 day hospital course

  17. IRIS • New symptoms of infection / inflammation in pt recently on antiretrovirals with: • Increasing CD4 (> 25 cells ) • > 1 log decrease VL • Most common pathogens • MAI • Cryptococcus • Hepatitis B

  18. Predictors of IRIS • > 1 prior OI • Low CD4 • Anemia • Antiretroviral naïve • Rapid decline in HIV • Proximity to recent OI

  19. Management of IRIS • Search for new OI • Continue antiretrovirals • ? Steroids- with caution

  20. References • Robertson J, Meier M, Wall J, et al. Immune Reconstitution Syndrome in HIV: Validating a Case Definition and Identifying Clinical Predictors in Persons Inititiating Antiretroviral Therapy. Clinical Infectious Diseases 2006; 42(11): 1639-46. • Ratnam I, Chiu C, Kandala N-B and Easterbrook PJ. Incidence and Risk Factors for Immune Reconstitution Inflammatory Syndrome in an Ethnically Diverse HIV Type 1-Infected Cohort. Clinical Infectious Diseases 2006; 42: 418-427. • Hirsch H, Kaufmann G, Sendi P and Battegay M. Immune Reconstitution in HIV-Infected Patients. Clinical Infectious Diseases 2004; 38(8)” 1159-1166.

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