Sohail Abdul Salim
1, Yougandhar V. Akula
1, Bettina B. Noszály
2, Sabahat Afshan
3, Mohit Agarwal
1, Tibor Fülöp
4,5*1 Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
2 Kossuth Lajos Preparatory and Demonstration School, University of Debrecen, Hungary
3 Department of Pediatrics, Division of Pediatric Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
4 Department of Medicine, Division of Nephrology, Faculty of Medicine, University of Debrecen, Hungary
5 FMC Extracorporeal Life Support Center, Fresenius Medical Care, Debrecen, Hungary
*Corresponding Author: *Corresponding author: Tibor Fülöp, M.D., FACP, FASN, Emails: tiborfulop.nephro@gmail.com, , Email:
fulopt@musc.edu
Abstract
Symptomatic cytomegalovirus (CMV) infections are rare in patients with no previous history
of immunosuppressive therapy or condition. A 33-year-old woman with type-2 diabetes, endstage
renal disease (ESRD) and unexplained lower extremity weakness was admitted with
failure to thrive, ongoing hemolysis, low haptoglobin and C3 levels and suppressed IgM and
IgG globulin fractions. Multiple cultures and serologic workup for autoimmune disorders
remained negative. CMV viral titer by serum polymerase chain reaction (PCR) revealed
massive elevation at 9.2 million copies/mL. Initial CMV IgG titer was positive, IgM titer
remained consistently negative and CMV was recovered from cerebrospinal fluid, as well.
She received treatment with I.V. ganciclovir, CMV immune globulin (CytoGam) and three
sessions of plasmapheresis (PLEX). The extreme viremia without neutropenia, lack of IgM
antibody reconversion and CMV-mediated hemolysis with a low complement level were all
very unusual features. Timely initiation of PLEX may have contributed to recovery
Implication for health policy/practice/research/medical education:
CMV disease and viremia in the malnourished, chronically ill patients may dramatically differ from those with prior organ
transplants. The absence of low white blood cell count or lack of CMV IgM reconversion are not sufficient alone to rule out the
clinical diagnosis, only viral DNA testing by PCR. Autoimmune hemolytic anemia with low complement level may occur in
some patients with CMV infection which may respond, in addition to specific antiviral therapy, to therapeutic plasma exchange.
Please cite this paper as: Salim SA, Akula YV, Noszály BB, Afshan S, Agarwal M, Fülöp T. Potential role of plasmapheresis
in severe cytomegalovirus infection with ongoing immune-mediated hemolysis and low complement level. J Renal Inj Prev.
2018;7(3):206-210. doi: 10.15171/jrip.2018.48.