Abstract:
We report a case of a neonate diagnosed with congenital cytomegalovirus (CMV) infection presenting with disseminated thrombosis, including superior mesenteric vein (SMV) and renal vein thrombosis (RVT). The infant was successfully treated with a combination of antiviral therapy (valganciclovir) and anticoagulation (enoxaparin), leading to clinical improvement and resolution of thrombotic events. This case underscores the importance of considering congenital CMV infection in neonates presenting with unusual thrombotic manifestations and highlights the efficacy of combined antiviral and anticoagulant therapy.
Introduction:
Cytomegalovirus is a member of the Herpesviridae family and is a significant pathogen in humans. While CMV infection is often asymptomatic, it can lead to severe complications, particularly in immunocompromised individuals and neonates. Thromboembolic events associated with CMV have been documented, though they are relatively rare. In neonates, congenital CMV infection can present with various clinical manifestations, but disseminated thrombosis involving vessels such as the SMV and renal veins is uncommon.
Case Presentation:
A full-term male neonate was born via spontaneous vaginal delivery to a 25-year-old primigravida mother with an unremarkable antenatal history. The infant had a birth weight of 3.2 kg and Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. On day 3 of life, the neonate developed abdominal distension and hematuria. Physical examination revealed a palpable abdominal mass on the left side.
Laboratory investigations showed thrombocytopenia (platelet count: 75,000/µL) and elevated liver enzymes (AST: 150 U/L, ALT: 120 U/L). Coagulation profiles were within normal limits. Ultrasonography of the abdomen revealed thrombosis in the SMV and left renal vein. Further evaluation for prothrombotic conditions, including protein C and S levels, antithrombin III, and factor V Leiden mutation, were negative.
Given the absence of common risk factors for neonatal thrombosis, congenital infections were considered. PCR testing of the infant’s urine confirmed CMV DNA, and serological tests indicated positive CMV IgM and IgG antibodies. Cranial ultrasound and ophthalmologic examination were unremarkable.
Treatment:
The neonate was initiated on oral valganciclovir at a dose of 16 mg/kg twice daily for a planned duration of 6 weeks. Concurrently, anticoagulation therapy with subcutaneous enoxaparin was started at 1.5 mg/kg every 12 hours, with dose adjustments based on anti-factor Xa levels.
Outcome:
The infant tolerated the treatment well, with no significant adverse effects. Serial ultrasounds demonstrated gradual resolution of the SMV and renal vein thrombosis over a 4-week period. Platelet counts normalized, and liver enzyme levels returned to baseline. At the 6-month follow-up, the child exhibited normal growth and development, with no evidence of recurrent thrombosis or CMV-related sequelae.
Discussion:
CMV has been implicated in thromboembolic events through various mechanisms, including endothelial cell activation and induction of a procoagulant state. While such associations are well-documented in adults, especially in immunocompromised patients, neonatal presentations are rare. A case report by Lanari et al. described neonatal aortic arch thrombosis associated with congenital CMV infection, highlighting the virus’s potential role in vascular thrombosis. In our case, the combination of antiviral therapy with valganciclovir and anticoagulation with enoxaparin was effective in resolving the thrombotic events, suggesting a synergistic approach in managing such cases.
Conclusion:
This case emphasizes the need for clinicians to consider congenital CMV infection in neonates presenting with atypical thrombotic events. Early diagnosis and prompt initiation of combined antiviral and anticoagulant therapy can lead to favorable outcomes.
References:
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- Walter G, Armstrong M, Finny G, et al. Acute superior mesenteric vein thrombosis in the setting of cytomegalovirus mononucleosis: a case report and review of the literature. Lancet Infect Dis. 2021;21(7):e202-e207.
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