Cytomegalovirus (CMV) Hepatitis

Family Medicine Clerkship

Cytomegalovirus (CMV) is a double stranded DNA virus and a member of the human
herpesvirus-5 (HHV-5) family. It is a widespread virus which infects close to 70% of the
population in the industrialized world and close to 100% of population in the developing
world. Transmission is mainly by body fluids such as saliva, blood, breast milk, urine,
cervical secretions, semen and organ transplantation. A vast number of host cells such as
hematopoietic, endothelial, epithelial, connective tissue and parenchymal cells can be
infected.

CMV infections can be asymptomatic in immunocompetent persons and life threatening in

immunocompromised persons. Congenital CMV can cause learning and intellectual
disabilities, deafness and even death.

CMV has the ability to modulate host cell cycle through a variety of complex mechanisms.
This creates an enabling environment for lifelong latent infection.
The exact mechanism by which CMV induces hepatitis is not certain but the competency of
one’s immunity appears to play a significant role.

Presentation
- can be asymptomatic or present with mild flu-like symptoms
- patient may present with fever of unknown origin
- fever, fatigue,pharyngitis, sore throat, enlarged lymph nodes and splenomegaly may
be present
- occasionally a rash, and abdominal pain

Differentials
- Viral hepatitis
- Epstein Barr virus
- HIV
- Infectious mononucleosis
- Human Herpesvirus 6 infection

Investigations
CMV hepatitis is diagnosed when bilirubin and/or LFTs are present, in addition to finding
CMV and no other cause for hepatitis.
The tests below help to differentiate between active, latent and previous exposures:
- CMV DNA PCR
- Viral culture
- CMV antibodies
 - CMV antigen assay
The DNA PCR is the most sensitive and specific test able to detect active infection while the
antibodies test can indicate previous exposure.
Viral culture can take 1 to 3 weeks to obtain results. False negatives can be obtained if
samples are taken too early.

Treatment

- immune competent persons with minimal or no symptoms do not require any specific
treatment as the infection is self limiting. Treatment should be based on symptomatic
management.
- in severe cases and in immunocompromised persons, antiviral therapy with
ganciclovir or valganciclovir are indicated.

Complications
- relapse is common in transplant patients

Prognosis
CMV hepatitis prognosis is usually good. A good number of patients recover completely
although symptoms in the form of fatigue can persist for many months after initial infection.
In immunocompromised patients, primary CMV infection, reinfection and reactivation are
common. Significant morbidity and mortality is unfortunately associated with this group of
patients.

References

1. Cedeno-Mendoza, R., & Vanchhawng Pedroza, L. (2021, July 7). Cytomegalovirus

[Review of Cytomegalovirus]. Medscape.
https://emedicine.medscape.com/article/215702-overview?icd=ssl_login_success_221
112
2. CMV Hepatitis: Risk Factors, Symptoms, Diagnosis, and Treatment. (2022, June 14).
Healthline. https://www.healthline.com/health/hepatitis-c/hepatitis-cmv
3. Da Cunha, T., & Wu, G. Y. (2021). Cytomegalovirus Hepatitis in Immunocompetent
and Immunocompromised Hosts. Journal of Clinical and Translational Hepatology,
000(000), 1–10. https://doi.org/10.14218/jcth.2020.00088
4. Gupta, M., & Shorman, M. (2020). Cytomegalovirus. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK459185/
5. Sattar, S. B. A., Haider, M. A., Zia, Z., Niazi, M., & Iqbal, Q. Z. (2020).
Cytomegalovirus Hepatitis in an Immunocompetent Patient: A Cause of Fever of
Unknown Origin. Cureus. https://doi.org/10.7759/cureus.10745