488 Cytomegalovirus pneumonia
Case Report
Cytomegalovirus Pneumonia Mimicking Lung Cancer
in an Immunocompetent Host
HELEN KARAKELIDES, MD; MARIE-CHRISTINE AUBRY, MD; AND JAY H. RYU, MD
Cytomegalovirus (CMV) pneumonia can be a life-threat-
ening disease in immunocompromised patients such as
transplant recipients and patients given immunosuppres-
sive therapy. Although CMV infections are highly preva-
lent in the general population, symptomatic pneumonia in
an immunocompetent adult has been documented rarely.
We describe a 47-year-old male smoker who presented
with a 3.5-cm cavitary mass in the upper lobe of the left
lung, highly suggestive of lung cancer. Wedge resection of
C ytomegalovirus (CMV), a member of the human her-
pesvirus group, causes the most severe disease syn-
dromes in immunocompromised patients. For example,
CMV pneumonia is the most common life-threatening infec-
tious complication in bone marrow transplant recipients.1 In
immunocompromised patients, CMV pneumonia usually
presents as diffuse interstitial infiltrates.1-4 Cytomegalovirus
infection is also common in the general population in whom
the manifestations range from no clinically apparent disease
to infectious mononucleosis syndrome.1 Cytomegalovirus
pneumonia has been documented rarely in immunocompe-
tent adults.1,2 We describe a patient with CMV pneumonia,
confirmed by surgical lung biopsy, who presented with a
cavitary mass that was suggestive of lung cancer; the patient
was a smoker but was otherwise a normal host.
REPORT OF A CASE
A 47-year-old man, a current smoker, presented to the
emergency department of a Mayo Clinic–affiliated hospital
in Rochester, Minn, for evaluation of left shoulder pain and
a lung mass recently noted at a hospital elsewhere. He
described a 6-week history of persistent left shoulder pain
and a productive cough that included 1 episode of hemop-
tysis. The patient experienced an unintentional weight loss
of 7 kg over this period but denied chest pain, shortness of
breath, fever, chills, risk factors for human immunodefi-
ciency virus (HIV) infection including intravenous drug
From the Department of Internal Medicine (H.K.), Division of Ana-
tomic Pathology (M.-C.A.), and Division of Pulmonary and Critical
Care Medicine and Internal Medicine (J.H.R.), Mayo Clinic, Roches-
ter, Minn.
Individual reprints of this article are not available. Address correspon-
dence to Jay H. Ryu, MD, Division of Pulmonary and Critical Care
Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
Mayo Clin Proc. 2003;78:488-490
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc, April 2003, Vol 78
the mass on thoracotomy revealed CMV pneumonia with
no evidence of malignancy or other infections. No antiviral
therapy was given to this immunocompetent patient, and
no additional manifestations of CMV disease occurred.
Mayo Clin Proc. 2003;78:488-490
AIDS = acquired immunodeficiency syndrome; CMV = cyto-
megalovirus; CT = computed tomography; HIV = human
immunodeficiency virus
use, or exposure to tuberculosis or birds. One week earlier,
he was evaluated at a hospital elsewhere; chest radiogra-
phy and subsequent computed tomography (CT) of the
chest revealed a left upper lung mass. He was taking no
medications and denied any important medical or surgical
history. The patient had a 40-pack-year history of cigarette
smoking. He had not traveled recently. Family history was
notable for colon cancer in his father.
The patient was afebrile with a normal blood pressure
level and pulse. Physical examination findings were nor-
mal with no pharyngitis, lymphadenopathy, hepatospleno-
megaly, or abnormalities on auscultation of the lungs. The
patient’s laboratory studies showed a normal hemoglobin
level and a normal total leukocyte count with mild lympho-
cytosis (57%). His serum alkaline phosphatase and aspar-
tate aminotransferase levels were mildly elevated at 618 U/L
and 50 U/L, respectively. Serum protein electrophoresis
was normal. His HIV-1 and HIV-2 antibody assays were
negative. Fungal serologies (Histoplasma, Blastomyces,
Coccidioides, Cryptococcus) were also negative. Delayed
hypersensitivity skin tests included a negative reaction to
purified protein derivative and a positive reaction to Can-
dida. Chest radiography (Figure 1) and contrast-enhanced
CT of the chest (Figure 2) showed a 3.5-cm cavitary mass
medially in the upper lobe of the left lung and mild left
mediastinal and hilar adenopathy. Radionuclide bone scan
revealed no evidence of metastatic disease.
Flexible bronchoscopy showed no endobronchial ab-
normalities. Bronchial brushings and washings revealed no
abnormal cells on cytologic examination. In addition, no
pathogens were isolated on bacterial, fungal, and myco-
bacterial cultures of bronchial washings. Transbronchial
biopsy showed CMV inclusions associated with mixed
inflammation. Immunoperoxidase staining of the biopsy
488 © 2003 Mayo Foundation for Medical Education and Research
Mayo Clin Proc, April 2003, Vol 78 Cytomegalovirus pneumonia 489

specimen was also positive for CMV. However, CMV was

believed not to reflect the true nature of the cavitary lung
mass, and a thoracotomy was performed for further evalua-
tion. Wedge excision of the left upper lung mass was
performed at thoracotomy; the resected specimen showed
acute and organizing pneumonia with florid reactive lym-
phoid hyperplasia forming a consolidated mass (Figure 3,
left). Several epithelial and endothelial cells were markedly
enlarged and contained both nuclear and cytoplasmic
inclusions typical of CMV (Figure 3, right), as confirmed
by immunohistochemical staining of the previous trans-
bronchial biopsy. These cytopathic changes were limited
to the area of organizing pneumonia. Special stains for
microorganisms, including Gram, Grocott-Gomori meth-
enamine–silver nitrate, and auramine-rhodamine, were
negative. No cytopathic features indicative of other types
of virus identifiable histologically were present. Immuno-
peroxidase staining revealed a polyclonal mixture of T
cells, B cells, and plasma cells consistent with reactive lym-
phoid hyperplasia. There was no neoplasm. The resected
specimen was cultured for bacteria, fungi, mycobacteria,
and viruses. Cytomegalovirus was the only pathogen
recovered.
No antiviral or any other antimicrobial therapy was
given because the patient was immunocompetent and was
not severely ill. The patient was examined again 7 months
after thoracotomy. He was well and had gained weight (1
kg). His left shoulder pain, productive cough, and lympho-
cytosis had resolved. His aspartate aminotransferase level
had decreased considerably (32 U/L), and his alkaline
phosphatase level had normalized. Chest radiographs
showed only postoperative findings with no relevant ab-
normalities. No recurrent pneumonia or other manifesta-
tions of CMV disease were evident.
Figure 1. Chest radiography shows a mass in the left suprahilar
region.
The prevalence of CMV pneumonia appears to be lower
in patients with acquired immunodeficiency syndrome
(AIDS) compared with that seen in transplant recipients.1,2
The appearance of CMV pneumonia on CT in patients with
AIDS has been similar to that described for other
immunocompromised patients.9 In addition, single or mul-
tiple nodules measuring between 1 and 3 cm have been
associated with CMV pneumonia occurring in patients
with AIDS.8,14,15 In one patient, a single thick-walled cavi-
tary lesion was described.9 In a retrospective review of 25
patients with AIDS and cavitary lung lesions, 3 were diag-
nosed as having CMV infection. However, 2 of these 3
patients were diagnosed as having CMV infection on the
basis of positive bronchial washings alone, ie, without
histopathologic confirmation.16
Our patient had no risk factor for, or evidence of, an
immunocompromised state. He recovered from his episode
of CMV pneumonia without antiviral therapy. Special

DISCUSSION
In immunocompromised patients such as transplant recipi-
ents, CMV infection may cause interstitial pneumonia, in-
flammatory or hemorrhagic nodules, focal areas of orga-
nizing pneumonia, and, in severe cases, diffuse alveolar
damage.1,2,5,6 Chest radiography usually reveals diffuse in-
terstitial infiltrates, but they occasionally can be limited to
1 lobe or appear consolidative.1,4,7 Findings on CT of the
chest include ground-glass opacities, dense consolidation,
poorly defined nodules, and, less commonly, irregular lin-
ear opacities.2-6,8-13 Ground-glass opacities represent early
changes of diffuse alveolar damage.5,6 Consolidation corre-
lates with interstitial pneumonia with associated edema and
fibrinous exudate.5,6 Micronodules seen on CT correspond
Figure 2. Computed tomography of the chest reveals a 3.5-cm
to inflammatory and hemorrhagic nodules and focal areas spicular, cavitary mass medially in the upper lobe of the left lung.
of organizing pneumonia.5,6 These changes usually are seen Additional focal infiltrates are seen along the left major fissure
diffusely in all lobes of the lung. and the right lung posteriorly.

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
490 Cytomegalovirus pneumonia
Figure 3. Left, Low-power photomicrograph shows an acute and organizing pneumonia forming a consolidated process (hematoxylin-
eosin, original magnification ×40). Right, High-power photomicrograph of an enlarged cell with the characteristic dark purple intranuclear
inclusion of cytomegalovirus admixed in a background of inflammatory cells (hematoxylin-eosin, original magnification ×400).
stains and cultures performed on bronchoscopic and surgi-
cal specimens showed no other infectious agents. Cytomeg-
alovirus pneumonia has been documented rarely in immu-
nocompetent hosts, and interstitial infiltrates have been
described in a few patients.1,17 The radiographic findings in
our patient were worrisome for lung cancer, particularly in
view of his smoking history, persistent shoulder pain, and
weight loss. For this reason, thoracotomy was performed
despite preliminary evidence of CMV infection obtained at
bronchoscopy. To our knowledge, our patient represents
the only case of CMV pneumonia presenting as a cavitary
lung mass in a normal host.
Eddleston et al17 reviewed 34 cases in the world literature
of severe CMV infection occurring in immunocompetent
individuals. A relatively high mortality rate was noted
among these patients, and the investigators recommended
specific antiviral therapy.17 However, the primary drug used
to treat CMV disease, ganciclovir, is associated with poten-
tial severe toxicities including bone marrow suppression,
renal impairment, infertility, and teratogenesis.18 In addition,
compelling data to support the use of this drug in this patient
population are lacking.18 Because of the relatively mild and
limited manifestations of CMV disease in our patient, we did
not believe antiviral therapy was indicated.
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