Co-infection of cytomegalovirus and Epstein-Barr virus-induced pneumonitis following hepatitis B reactivation in an esophageal cancer patient: A case report.

RATIONALE: Cytomegalovirus (CMV) and/or Epstein-Barr virus (EBV) infection or reactivation is widely recognized in immunocompromised individuals, particularly those undergoing transplantation or those with acquired immune deficiency syndrome. There are reports of EBV-CMV co-infection or reactivation; however, this co-infection-induced pneumonitis has rarely been seen in patients outside these settings.

PATIENT CONCERNS: A 64-year-old male with previously treated pulmonary tuberculosis, positive hepatitis B surface antigen and a squamous cell carcinoma of the esophagus underwent 5 cycles of concurrent radiochemotherapy with weekly carboplatin and paclitaxel. Following treatment completion, the patient developed reactivated hepatitis B, requiring antiviral therapy initiation. Six weeks after completing radiochemotherapy, the patient experienced fever and dyspnea.

DIAGNOSES: The initial chest computed tomography scan revealed honeycomb-like, triangular, mixed alveolar-interstitial opacification in both lungs. Due to a poor clinical response to empiric antibiotics and negative results for both blood and sputum cultures, a bronchoalveolar lavage sample was obtained and revealed high viral loads of EBV and CMV, suggesting EBV-CMV pneumonitis.

INTERVENTIONS: Treatment with ganciclovir and corticosteroids resulted in significant clinical improvement, with marked resolution of lesions observed on computed tomography scans.

OUTCOMES: The patient was discharged in stable condition. However, 4 weeks later, while still on corticosteroid taper, the patient developed a recurrence of fever that progressed to respiratory failure, and was subsequently diagnosed with respiratory aspergillosis. The patient passed away after 1 week.

LESSONS: This case highlights the importance of suspecting CMV and/or EBV pneumonitis in patients undergoing chemotherapy and no response to empiric antibiotics. Timely detection of causative pathogens is important, as prompt intervention can markedly improve patient outcomes.