Cytomegalovirus Co-infection Complicating Severe Pneumonia in a Critically Ill Elderly Patient Without Classical Immunosuppression

Herikurniawan^1*, Aziza Harris¹

¹Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo National Hospital.

*Corresponding author. Phone: 085643606817; Email: herikurniawan.md@gmail.com

ABSTRACT

Background: Cytomegalovirus (CMV) infection is typically associated with immunocompromised hosts; however, its role in critically ill patients without classical immunosuppression is increasingly recognized. In the setting of severe illness, factors such as systemic inflammation, immune dysregulation, and underlying comorbidities may predispose to opportunistic infections and viral reactivation. Aging-related immune dysfunction, or immunosenescence, may further contribute to this vulnerability in older adults.

Case Presentation: We report a case of an 82-year-old female with multiple comorbidities, including chronic kidney disease on hemodialysis, atrial fibrillation, heart failure, and diabetes mellitus, who was admitted with decreased level of consciousness. She subsequently developed acute respiratory failure due to severe pneumonia requiring intensive care and mechanical ventilation. Microbiological evaluation identified NDM-producing Klebsiella pneumoniae. Despite appropriate antibacterial therapy, the patient showed suboptimal clinical improvement, prompting additional evaluation. Subsequent investigation consistent with CMV reactivation, with a viral load of 4.75 × 10³ IU/mL, consistent with viral reactivation. Laboratory findings demonstrated significant systemic inflammation, including elevated C-reactive protein (145 mg/L), procalcitonin (1.44 ng/mL), and leukocytosis. Following initiation of antiviral therapy, the patient demonstrated gradual clinical improvement with stabilization of respiratory status.

Conclusion: Elderly patients with multimorbidity may represent a functionally immunocompromised population. CMV should be considered as a potential co-infection in severe or non-resolving pneumonia in critically ill patients, particularly when the clinical course is prolonged or fails to respond to appropriate antimicrobial therapy. This case underscores the diagnostic challenge and clinical relevance of CMV reactivation in functionally immunocompromised elderly patients without classical immunosuppression.

Keywords: Cytomegalovirus; severe pneumonia; critically ill; elderly; immunosenescence; viral reactivation

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Doi : 10.2614/ijc.v12i3