What are the symptoms of Cytomegalovirus (CMV) infection?

Symptoms of Cytomegalovirus (CMV) Infection

CMV infection presents with a wide spectrum of clinical manifestations ranging from asymptomatic infection to severe end-organ disease, with symptoms varying based on the patient's immune status and the affected organ systems. 1

Common Systemic Symptoms

• Fever
• Weight loss
• Fatigue
• Malaise

Organ-Specific Manifestations

Ocular Manifestations (Most Common)

• Retinitis:
  • Floaters
  • Scotomata (blind spots)
  • Peripheral visual field defects
  • Central vision loss if macula or optic nerve affected
  • Characteristic "brushfire pattern" progression with fluffy yellow-white retinal lesions
  • Intraretinal hemorrhage may be present
  • Blood vessels near lesions may appear sheathed 2

Gastrointestinal Manifestations

• Colitis (second most common, 5-10% of cases):

  • Fever
  • Weight loss
  • Anorexia
  • Abdominal pain
  • Debilitating diarrhea
  • Malaise
  • Potential complications: mucosal hemorrhage and perforation (can be life-threatening) 2

• Esophagitis (<5-10% of cases):

  • Fever
  • Odynophagia (painful swallowing)
  • Nausea
  • Mid-epigastric or retrosternal discomfort 2

• Other GI manifestations:

  • Oral and esophageal ulcers
  • Hepatic involvement
  • Ascending cholangiopathy
  • Gastritis 1

Neurological Manifestations

• Encephalitis/Dementia:

  • Lethargy
  • Confusion
  • Fever (may mimic HIV-related dementia)
  • CSF findings: lymphocytic pleocytosis, low-to-normal glucose, normal-to-elevated protein 2

• Ventriculoencephalitis:

  • Acute course
  • Focal neurologic signs
  • Cranial nerve palsies
  • Nystagmus
  • Rapid progression
  • Periventricular enhancement on CT/MRI 2

• Polyradiculomyelopathy:

  • Guillain-Barré-like syndrome
  • Urinary retention
  • Progressive bilateral leg weakness
  • Loss of bowel and bladder control
  • CSF findings: neutrophilic pleocytosis (100-200 neutrophils/μL), hypoglycorrhachia, elevated protein 2

Pulmonary Manifestations

• Pneumonitis (uncommon):
  • Shortness of breath
  • Dyspnea on exertion
  • Nonproductive cough
  • Hypoxemia
  • Interstitial infiltrates on chest radiograph 2, 1

Laboratory Findings

• Lymphocytosis (up to 50% lymphocytes)
• Atypical lymphocytes (up to 9%)
• Elevated liver transaminases
• Anemia
• Thrombocytopenia
• Elevated lactic dehydrogenase 1

Special Considerations by Immune Status

Immunocompetent Hosts

• Usually asymptomatic or mild, self-limited disease
• May present as mononucleosis-like syndrome 3, 4
• Can occasionally cause severe disease requiring antiviral therapy 5

Immunocompromised Hosts

• More severe manifestations, especially in:
  • HIV/AIDS patients (particularly with CD4+ counts <50 cells/μL)
  • Transplant recipients
  • Patients with advanced immunosuppression 2
• Higher risk of end-organ disease and mortality
• Retinitis more common with CD4+ counts <100/μL 1
• Disease progression is typically more rapid and aggressive 2

Clinical Progression

Without treatment or immune recovery, CMV retinitis invariably progresses within 10-21 days after presentation, with a characteristic "fits and starts" pattern 2. Other manifestations may also progress rapidly, particularly in immunocompromised hosts.

Diagnostic Considerations

CMV should be considered in the differential diagnosis for various clinical syndromes, even in immunocompetent patients with prolonged or severe symptoms. A negative CMV IgG generally rules out CMV as the cause of symptoms, though seroreversion can occur in advanced immunosuppression 1.