454: INTUBATED, IMMUNOSUPPRESSED, AND INADEQUATE RECOVERY: A CASE OF CYTOMEGALOVIRUS (CMV) PNEUMONITIS

Introduction: Cytomegalovirus (CMV) pneumonitis is a rare opportunistic infection that occurs in patients receiving solid organ transplants, especially those with lung transplants. However, the incidence in bone marrow transplant patients is rare and has a high mortality rate. Description: A 31-year-old female with a medical history of stage IV Hodgkin’s lymphoma in remission s/p chemotherapy and radiation and recent bone marrow transplant on immunosuppression presents with new onset fever. Her family history is non-significant and she is a non-smoker with no alcohol and polysubstance use. Her vitals were stable except for a temperature of 101°F and physical examination revealed bilateral crackles in her lungs. Labs were significant for neutropenia, anemia, and thrombocytopenia. Imaging of her chest revealed patchy ground glass opacities. She was started on Vancomycin, meropenem, and azithromycin. During her course of stay in the hospital, she continued to spike fevers despite being on antibiotics. Despite repeated blood and urine cultures, there was no growth. She also developed progressively worsening hypoxia for which we decided to perform bronchoscopy and bronchoalveolar lavage (BAL). However, following her bronchoscopy she developed respiratory distress and was put on high-flow oxygen supplementation. As her respiratory distress worsened, she was then intubated for mechanical ventilatory support and was started on fluconazole and nystatin. However, there was an inadequate improvement in her respiratory status and we were unable to wean her off the ventilator. Her BAL microbiology analysis resulted positive for CMV PCR. Following these results, we started her on Ganciclovir, and given her underlying immunosuppressed condition with severe ARDS, we also administered CMV immunoglobulin. Her CMV viremia progressively downtrended from 104,000 copies to an undetectable level (< 200). Her clinical condition also improved with decreasing oxygen requirements and she was successfully extubated after 19 days of mechanical ventilation. Discussion: Although relatively rare, CMV-induced pneumonitis is associated with adverse outcomes and increased mortality. BAL remains a cornerstone in guiding the diagnosis of such patients resulting in early treatment and recovery.