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Acquired CMV


KEY FACTS

Terminology

  • Acquired CNS cytomegalovirus (CMV) infections: Meningitis, encephalitis, ventriculitis, transverse myelitis, radiculomyelitis, chorioretinitis

  • Immunocompromised (AIDS, organ transplant) patients are at risk → reactivation of previously silent infection

Imaging

  • Best diagnostic clue: Ventriculitis with fluid-debris level and ependymal enhancement in immunocompromised patient

  • Encephalitis: Ill-defined T2-hyperintense area, variable enhancement

  • May mimic HIV encephalitis with patchy nonspecific T2-hyperintense lesions

  • Contrast should be used for imaging of all immunocompromised patients

Top Differential Diagnoses

  • HIV encephalitis

  • Progressive multifocal leukoencephalopathy (PML)

  • Toxoplasmosis

  • Acute disseminated encephalitis

Clinical Issues

  • Primary CMV infection is generally asymptomatic

  • Infection may occur secondary to reactivation of latent viral infection or newly acquired via organ or bone marrow transplant from seropositive donor

    • CMV disseminates to CNS in late stages of HIV infection, low CD4(+) count (usually ≤ 50)

    • Clinically may mimic HIV encephalitis

  • M > > F

  • Disease manifestations vary in severity depending on degree of host immunosuppression

  • HAART

    • Markedly ↓ incidence of CMV disease in AIDS

    • ↑ Immunocompetence against CMV

Axial FLAIR MR shows mild ventriculomegaly and periventricular hyperintensities
related to ventriculo-encephalitis.

Axial T1WI C+ MR in the same patient shows ependymal
and periventricular
enhancement. This patient was immunocompromised with ventriculitis and associated encephalitis. CMV encephalitis is commonly a ventriculo-encephalitis, involving the periventricular white matter. However, CMV may also cause hemorrhagic or necrotic lesions.

Axial DWI MR in a 35-year-old HIV-positive patient with very low CD4(+) cell count demonstrates thin hyperintense rim along the ventricular margins
. There is mild enlargement of the ventricles and mild cortical atrophy.

Coronal T1WI C+ MR in the same patient shows subtle ependymal enhancement along the frontal horns
. Imaging findings are characteristic of CMV ventriculitis.

TERMINOLOGY

Abbreviations

  • Cytomegalovirus (CMV) infection

Definitions

  • Acquired CNS infections: Meningitis, encephalitis, ventriculitis, retinitis, polyradiculopathy, myelitis

  • Primary CMV infection: Generally asymptomatic in healthy adults

  • Immunocompromised (AIDS, organ transplant) patients at risk → reactivation of previously silent infection

IMAGING

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