Cytomegalovirus infection in heart transplant patient presenting as appendicitis

Abstract

Cytomegalovirus (CMV) may manifest in various ways. While immunocompetent hosts may be asymptomatic or present with a mononucleosis-like illness, immunocompromised patients can have organ-specific disease capable of significant morbidity and mortality. CMV appendicitis is a particularly rare presentation. A 22-year-old female with a history of orthotopic heart transplantation presented to our hospital with a three-day history of worsening abdominal pain. A computed tomography scan of her abdomen was consistent with acute uncomplicated appendicitis, and she underwent laparoscopic appendectomy. Pathology revealed acute appendicitis with numerous large cells with intranuclear "owl's eye" inclusions characteristic of CMV. Her CMV viral load was elevated at 327,018 IU/ml. She was started on ganciclovir which resulted in improvement of her CMV level to 30,118 IU/ml within three weeks. CMV is a frequent cause of opportunistic infection in solid organ transplant patients and commonly involves the gastrointestinal tract. Acute appendicitis is a rarely reported complication to consider in the differential diagnosis of abdominal pain in immunocompromised patients.

Learning objective: Heart transplant recipients are at increased risk for opportunistic infections. Cytomegalovirus (CMV) is a frequent culprit and can present with a broad range of disease. A particularly rare presentation is that of acute appendicitis. We describe a case of a young woman with CMV appendicitis following orthotopic heart transplant.

Keywords: Appendicitis; Cytomegalovirus; Heart transplant; Immunosuppression.

Fig. 1

Computed tomography scan of the abdomen showing a 5-mm appendicolith with mild dilatation and wall thickening of the appendix (blue arrows), consistent with acute appendicitis.

Fig. 2

(A) Cytomegalic cells with intranuclear “owl's eye” inclusions (400× magnification, hematoxylin and eosin stain). (B) Immunostain for cytomegalovirus highlights numerous viral inclusions (200× magnification).