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J Thorac Cardiovasc Surg 1996;112:547-548
© 1996 Mosby, Inc.
BRIEF COMMUNICATIONS |
Osaka, Japan
From the First Department of Surgery,a Department of Intensive Care,b Osaka University Medical School, Osaka, Japan.
Received for publication Oct. 27, 1995; Accepted for publication Oct. 30, 1995. Address for reprints: Norihide Fukushima, MD, First Department of Surgery, Osaka University Medical School, 2-2 Yamada-Oka, Suita, Osaka 565, Japan.
Cytomegalovirus (CMV) has long been known to be fatal to immunocompromised patients. It has been widely recognized that patients undergoing cardiovascular operations, especially open heart operations, are susceptible to CMV infection.
1 The majority of these infections, however, are subclinical and only a small percent of these individuals have a more severe illness characterized by fever and liver injury. 2 Thus CMV infection after cardiac operations has not been considered a serious disease for a long time. However, recent reports have emphasized that CMV infection after heart operations may be far more sinister. 2,3 In this report, we describe two cases of multiple organ failure and CMV pneumonia after cardiovascular operation. We also discuss the methods of diagnosis and treatment for CMV infection.
CASE 1
A 47-year-old woman underwent open mitral commissurotomy and tricuspid annuloplasty. The CMV titer was 1:256 before the operation. She had aspiration pneumonia on the second postoperative day, which necessitated extracorporeal membrane oxygenation. She was treated successfully and weaned from extracorporeal membrane oxygenation on the sixth postoperative day, with an increase in arterial oxygen pressure (Pao2). Pao2 decreased again, however, and the chest x-ray film showed interstitial pneumonitis in both lungs on the tenth postoperative day. Polymerase chain reaction (PCR) test 4 for CMV in the bronchoalveolar lavage specimen and the blood yielded a CMV-positive result on the eleventh postoperative day. Hyper-CMV immune globulin (polyglobulin) in a dose of 500 mg/day and ganciclovir in a dose of 2.5 mg/kg per day were given intravenously for 3 and 14 days, respectively. Findings of interstitial pneumonitis in the chest x-ray film almost disappeared, and Pao2 increased from 180 to 540 mm Hg at an inspired oxygen fraction of 1.0. PCR and culture for CMV in the blood yielded CMV-negative results. She was weaned from a respirator on postoperative day 22, but she died of multiple organ failure combined with systemic Serratia infection on POD 101.
CASE 2
A 51-year-old woman underwent aortic valve replacement, open mitral commissurotomy, tricuspid annuloplasty, and left atrial plication. Delayed sternal closure was done. The CMV titer was 1:512 before the operation. She underwent intraaortic balloon pumping and continuous venovenous hemodialysis and had sepsis as a result of methicillin-resistant Staphylococcus aureus. The chest x-ray film showed interstitial pneumonitis in both lungs on postoperative day 22, and Pao2 was decreasing. PCR for CMV virus of the bronchoalveolar lavage specimen and the blood yielded CMV-positive results on postoperative day 22. Polyglobulin and ganciclovir were given in the same doses as in case 1. Findings of interstitial pneumonitis in both lungs became unremarkable and Pao2 increased. Although PCR yielded CMV-negative results on postoperative day 42, Pao2 decreased again and the woman died of multiple organ failure combined with systemic Serratia infection on the postoperative day 43.
Comments
CMV infection has not been considered to be severe in individuals not affected by immunocompromise, including patients having cardiothoracic operations. 1 However, it has been reported recently that even previously healthy adults may also contract severe CMV infection, such as CMV pneumonia. 5 Moreover, recent reports indicated the possibility that patients might manifest severe CMV infection after heart operations. 2,3 In the present report, two patients who had not been immunocompromised and CMV seropositive before their operations had CMV pneumonia after cardiovascular operations, and both died of multiple organ failure even though CMV culture of the blood became negative. Thus CMV infection should be considered to be a much more severe illness, even in patients who are not immunocompromised.
The presence of CMV in bronchoalveolar lavage specimen or blood is not in itself definitive evidence of CMV diseases, because it is important to distinguish between CMV infection resulting from viral reactivation and CMV disease itself, that is, CMV pneumonia. Before the present study, PCR tests for CMV were done in 20 normal subjects and 26 nonimmunocompromised cardiovascular patients with positive CMV antibody titer, but none had positive PCR results for CMV. PCR tests and culture for CMV were done in 10 patients with interstitial pneumonia after cardiac operations. The present two patients had CMV-positive results, whereas the remaining eight patients had CMV-negative results. Therefore our method for PCR is a highly specific means of diagnosing CMV-related disease.
In conclusion, the present study demonstrates that severe CMV infection, such as CMV pneumonia, can occur in patients having cardiac operations. If interstitial pneumonia is suspected, CMV infection should be sought as soon as possible, even in patients who were not immunocompromised before the operation or who were seropositive for CMV.
References
This article has been cited by other articles:
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  N. Fukushima, S. Ohtake, Y. Sawa, M. Nishimura, G. Matsumiya, S. Takashima, M. Hori, R. Shirakura, and H. Matsuda Follow-Up on Heart Transplant After Left Ventricular Assist System Bridge Asian Cardiovasc Thorac Ann, December 1, 2001; 9(4): 312 - 314. [Abstract] [Full Text] [PDF]
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