Letter to the Editor
Splenic infarction due to cytomegalovirus infection in an immunocompetent patient
Infarto esplénico por citomegalovirus en un paciente inmunocompetente
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It is also emphasized that this incidence is likely underestimated due to the lack of study of thrombotic events in these patients.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> We report the case of a patient with splenic infarction secondary to a CMV infection and its literature review.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 63-year-old woman with hypertension and dyslipidemia. Routine therapy with indapamide and atorvastatin. The patient consulted for 3 weeks of malaise, asthenia and fever (37–39<span class="elsevierStyleHsp" style=""></span>°<span class="elsevierStyleSmallCaps">C</span>), being normal the rest of the anamnesis. No epidemiological factors of interest.</p><p id="par0015" class="elsevierStylePara elsevierViewall">At admission, BP 110/60<span class="elsevierStyleHsp" style=""></span>mmHg, HR 70<span class="elsevierStyleHsp" style=""></span>bpm, T 37.8<span class="elsevierStyleHsp" style=""></span>°C. On examination she showed no significant anomalies, except submandibular and bilateral inguinal, painful lymphadenopathies.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Blood test with leukocytosis by 13,000<span class="elsevierStyleHsp" style=""></span>leukocytes/mm<span class="elsevierStyleSup">3</span>, 3% activated lymphocytes and 32% naive lymphocytes. AST 114<span class="elsevierStyleHsp" style=""></span>U/l (5–34), ALT 137<span class="elsevierStyleHsp" style=""></span>U/l (5–55), GGT 134<span class="elsevierStyleHsp" style=""></span>U/l (9–36), FA 100, LDH 430 (125–220) and bilirrubin 0.7<span class="elsevierStyleHsp" style=""></span>mg/dl. Normal kidney function, Na<span class="elsevierStyleSup">+</span> 127<span class="elsevierStyleHsp" style=""></span>mmol/l, K<span class="elsevierStyleSup">+</span> 3.5<span class="elsevierStyleHsp" style=""></span>mmol/l, Cl<span class="elsevierStyleSup">−</span> 101<span class="elsevierStyleHsp" style=""></span>mmol/l, PCR 74<span class="elsevierStyleHsp" style=""></span>mg/l (0–5). Positive lupus anticoagulant (Rusell), negative EBV, negative HIV and blood cultures and negative urine culture test. With positive result for CMV IgM 4 S/CO (positive<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Within the study, abdominal CT was requested, showing a spleen with a globular shape compatible with splenic infarction and mesenteric adenitis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A study was completed evaluating the different causes of splenic infarction, taking a detailed anamnesis that ruled out any traumatic causes; complete blood test ruled out myeloproliferative syndromes and hemoglobinopathies, and echocardiogram ruled out emboligenic source.</p><p id="par0035" class="elsevierStylePara elsevierViewall">With the tests performed, the diagnosis was acute CMV infection with secondary splenic infarction.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We decided to wait and monitor the evolution, noticing clinical improvement and negativization of the lupus anticoagulant activity. Follow-up 3-month CT scan, showed an image compatible with previous splenic infarction, with improvement of the rest of the anomalies.</p><p id="par0045" class="elsevierStylePara elsevierViewall">CMV is a DNA virus of the herpesviridae family.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> CMV infection in immunocompetent persons is common, but most of them tend to be asymptomatic or it may present as a mild mononucleosis syndrome.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> On the other hand, in immunocompromised patients, it behaves like an opportunistic pathogen and can lead to serious clinical symptoms, such as pneumonitis, hepatitis, retinitis or encephalitis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The association of CMV with thromboembolic complications has always been considered a more common complication of immunocompromised patients. However, more recent publications have described several cases in immunocompetent persons. A meta-analysis of 97 published cases with CMV infection associated with thrombosis showed that two thirds of the cases involved immunocompetent persons.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Deep vein thrombosis is more common in immunocompromised patients and splenic infarction in immunocompetent patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Different theories relate CMV infection with thrombosis. The most common is the transient production of antiphospholipid antibodies due to CMV, which disappear or decrease after infection. Another theory is the changes in the cell membrane caused by the infection of the endothelial cells, which activates the adhesion of platelets and leukocytes, as well as the coagulation factor X. The third theory states that CMV is capable of activating factor 8.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The first treatment for thrombosis is managing the underlying cause, in this case treating CMV with ganciclovir or valganciclovir, in addition to anticoagulant therapy.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, a patient with splenic infarction should be studied for potential CMV infection. However, more studies are required to be able to routinely recommend a thrombosis test in cases of CMV infection.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Redondo A, Jarne V, Arteaga M. Infarto esplénico por citomegalovirus en un paciente inmunocompetente. Med Clin (Barc). 2019;152:e69–e70.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infección por citomegalovirus humano" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. 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