A Case of Granulomatosis with Polyangiitis Complicated by Ganciclovir-Resistant Cytomegalovirus Central Nervous System Infection

Mohammad  Sadidi; Mahdieh  Iranmanesh; Sanaz Heydari  Havadaragh

doi:10.18502/crcp.v10i3.20315

Mohammad Sadidi Department of Rheumatology, Amir Alam Hospital, Tehran University of Medical Sciences, Tehran, Iran.
Mahdieh Iranmanesh Department of Infectious Disease, Amir Alam Hospital, Tehran University of Medical Sciences, Tehran, Iran.
Sanaz Heydari Havadaragh Department of Neurology, Amir Alam Hospital, Tehran University of Medical Sciences, Tehran, Iran.

DOI: https://doi.org/10.18502/crcp.v10i3.20315

Keywords: Granulomatosis with polyangiitis; Cytomegalovirus; Meningoencephalitis; Ganciclovir; Foscarnet; Immunosuppression

Abstract

This case report describes a 72-year-old female with a confirmed diagnosis of Granulomatosis with Polyangiitis (GPA), who developed a complex and ultimately fatal clinical course complicated by refractory cytomegalovirus (CMV) meningoencephalitis. Despite initial immunosuppressive treatment for GPA and subsequent antimicrobial therapies for suspected bacterial and fungal infections, the patient presented with recurrent fevers, delirium, and cerebrospinal fluid (CSF) pleocytosis. Repeated CSF analyses and imaging revealed a perplexing picture, with a final diagnosis of CMV infection of the central nervous system (CNS) confirmed by PCR. The infection proved resistant to first-line antiviral therapy with ganciclovir, necessitating the addition of foscarnet. The patient’s condition deteriorated, culminating in aspiration pneumonia, hemodynamic instability, and death. This case highlights the diagnostic challenges of CNS infections in immunosuppressed patients and the potential for severe, treatment-resistant viral opportunistic infections in the context of GPA and its treatment.