COVID-19 and Cytomegalovirus Co-infection: A Challenging Cas
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COVID-19 is a severe disease that has reached pandemic status. To the best of knowledge, this is the first case of COVID-19 and cytomegalovirus (CMV) co-infection in a critically ill patient.

A 62-year-old male patient presented with a 1-week history of fever without cough or dyspnoea. Clinical examination revealed hypoxaemia, while CT of the thorax showed ground-glass opacities involving 50% of the lung parenchyma. A SARS-CoV-2 PCR test was positive.

By day 7 of hospitalization, the patient had developed severe ARDS, and was being managed with orotracheal intubation, vasoactive drugs, corticosteroids, prone position and prophylaxis for venous thromboembolism (VTE). Then, he presented a hemothorax due to an expontaneous pulmonary bleeding managed by thoracotomy and a partial inferior lobectomy. He also developed acute renal failure requiring dialysis. However, despite his severe condition, over the next 3 weeks, the patient improved clinically while continuing with dialysis but without oxygen supplementation or haemodynamic instability.

On day 30 of hospitalization, he presented with abdominal distention and pain. An abdominal CT scan revealed jejunal thickening with no evidence of mesenteric ischaemia. On day 38 of hospitalization, the patient complained again of abdominal distention, pain and nausea/vomiting and showed haemodynamic instability, lactic acidosis, leucocytosis and D-dimer levels worsening to 20,622 ng/ml FEU. This clinical picture suggested a vascular abdominal syndrome. A CT scan of the abdomen revealed small bowel thickening and vascular engorgement, without arterial obstruction.

Histological findings showed ulcerated lesions with inflammatory infiltrate and evidence of virus-induced cytopathic effects. IHC was positive for CMV infection and negative for herpes virus infection. Serum PCR for CMV reached 308,000 IU/ml. Ganciclovir was then started and 72 hours later abdominal distension resolved, diarrhoea reduced, and laboratory test results improved, permitting food to be administered to the patient through a nasogastric tube. He completely recovered and was discharged from hospital.

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