S3469 Cytomegalovirus (CMV) Infection Presenting as Acute Cholecystitis in an Immunocompetent Patient

Abstract

Introduction: Immunocompromised patients are at an increased risk for Cytomegalovirus (CMV) infections. There are only a few cases of CMV cholecystitis described in literature to date, but all are in immunocompromised patients. We report the first known case of an immunocompetent patient who presented with CMV cholecystitis. Case Description/Methods: 29-year-old female with history of cirrhosis secondary to autoimmune cholangitis (no history of immunosuppressive therapy), variceal bleed, listed for liver transplant, recurrent choledocholithiasis requiring ERCP, presented with acute right upper quadrant abdominal pain with sepsis. Abdominal ultrasound was equivocal, but presentation was suggestive of acute cholecystitis. Due to her complicated history, an elective robotic cholecystectomy was performed. Pathology results showed findings of acute cholecystitis with CMV cytopathic effect with positive immunohistochemistry (Figure). CMV PCR was positive with a load of 2.56 log (365 IU/ml plasma) at time of presentation. Serum CMV IgG 6 months prior, as part of liver transplant workup was negative suggesting acute CMV infection. She underwent liver biopsy, colonoscopy and endoscopy which were all CMV negative. CMV viremia spontaneously resolved and thus treatment was not initiated. Discussion: Immunocompromised patients developing CMV infections often present with wide range of symptoms that affect multiple organs and are often associated with substantial mortality. Immunocompetent individuals present with milder symptoms such as prolonged fever, fatigue, myalgia, or abnormal liver enzymes and only rarely with organ involvement such as colitis, pneumonia, pericarditis, myocarditis or retinitis. Few cases of CMV cholecystitis have been described in patients with acquired immunodeficiency syndrome (AIDS) and renal transplant recipients. However, this is the first known report of gallbladder-related CMV disease in an immunocompetent individual. Also, while this case represents an acute CMV infection, CMV reactivation can occur in cirrhotic patients. CMV reactivation is associated with more aggressive decompensation symptoms and impaired liver function, but symptomatic infection is rare. Our patient was not on immunosuppressive medications but presented with localized CMV disease in form of acute cholecystitis. This case raises the question that immunity may be compromised in hepatobiliary area in cirrhosis which may explain why she experienced the local CMV disease.Figure 1.: A) Low-power image of gallbladder showing acute and chronic cholecystitis with CMV cytopathic effect; insets show high-power image of CMV cytopathic effect and positive immunohistochemistry staining for CMV. B) Liver biopsy showing portal fibrous expansion with neocholangioles, bilirubinostasis and minimal inflammation.