Fatal disseminated cytomegalovirus infection with necrotizing oophoritis in a patient with acquired immunodeficiency syndrome

Abstract

Disseminated human cytomegalovirus (CMV) disease occurs mainly as a congenital infection and among immunocompromised hosts. Patients with acquired immunodeficiency syndrome (AIDS) are at increased risk for CMV infection, and the most prevalent clinical manifestation is retinitis, followed by colitis, esophagitis, pneumonitis, and encephalitis. CMV oophoritis is poorly described in the literature with some cases reported in patients with hematological or solid malignancies, bone marrow or solid organ transplantation, immunosuppressive therapy, and advanced AIDS cases. We report the case of a 61-year-old woman with a recent diagnosis of AIDS, which was associated with a wasting syndrome. The patient presented with abdominal pain, headache, cutaneous vesicular lesions on the abdomen, anemia, lymphopenia, and hyponatremia; she died suddenly on the fourth day of hospitalization. The autopsy was performed and demonstrated disseminated CMV infection with hemorrhagic encephalitis as the immediate cause of death. Additionally, pneumonitis, extensive adrenalitis, ulcerated enteritis, focal hepatitis, and necrotizing oophoritis were found.

Keywords: Acquired Immunodeficiency Syndrome; Autopsy; Cytomegalovirus; Oophoritis.

Figure 1. Cytomegalovirus (CMV) encephalitis: A – Gross view showing subarachnoid hemorrhage in the base of the brain, with a clot compressing the cerebellum and brain stem; B – Cortical area with subarachnoid encephalitis, parenchymal cells with CMV cytopathic effect, and a focus of neutrophilic abscess (arrow) (H&E, 110X); C – Various cerebral cells with characteristic CMV cytopathic effect: cytomegaly associated with intranuclear inclusions surrounded by a clear halo. Note discrete neutrophilic reaction and a small cortical vessel with endothelial tumefaction and cytomegalic endothelial cells collapsing the lumen (arrow) (H&E, 30X); D – In the center, a liver parenchymal cell is shown with CMV nuclear and cytoplasmic inclusions, surrounded by few neutrophils (IPX, 400X).

Figure 3. Micrograph of cytomegalovirus (CMV) oophoritis. A – Congestion, wedge cortical necrosis (arrow) and corpus albicans (H&E, 40X); B – Vessels in the base of wedge cortical necrosis showing fibrinoid necrosis (arrows) and various cytomegalic stromal cells (H&E, 100X); C – Endothelial cell with CMV-cytopathic effect (arrow and inset) near to necrotic areas with a discrete inflammatory reaction (H&E, 300X); D – Immunohistochemistry reaction showing ovarian stromal cells with CMV antigen in the nuclei and cytoplasm (IPX, 400X).

Figure 2. Micrograph of cytomegalovirus (CMV) adrenalitis. A – Medullary cells with CMV-cytopathic effect associated with moderate inflammatory reaction composed of histiocytes, lymphocytes, and neutrophils (H&E, 200X); B – Adrenal endothelial cells with CMV-cytopathic effect (arrows) (H&E, 400X); C – Adrenal cells with CMV-cytopathic effect with various aspects, one of them resembling a Reed–Stenberg cell or the “owl’s eyes” aspect (arrow) (H&E, 400X); D – A group of adrenal medullary cells with non-characteristic CMV-cytopathic effect (arrows) (H&E, 200X).

Figure 4. A – Micrograph of cytomegalovirus (CMV) hepatitis. In the center, a liver parenchymal cell with CMV nuclear and cytoplasmic inclusions, surrounded by few neutrophils (H&E, 400X); B – Micrograph of the lung in disseminated CMV infection, showing interstitial pneumonitis with a lymphomononuclear inflammatory infiltration in the interlobular septa and the alveolar septa. Note an intra-alveolar cell with CMV cytopathic effect (arrow) (H&E, 250X).

Figure 5. Micrograph of skin in disseminated cytomegalovirus (CMV). Discrete spongiosis and a superficial perivascular dermatitis exhibiting endothelial tumefaction and cells with typical CMV cytopathic effect (arrow). Note a perivascular cell with cytomegaly and only granular cytoplasmic viral inclusions (arrowhead) (H&E, 250X).