Disseminated Cytomegalovirus (Cmv) Infection in a Patient With Critically Low Cd4+ Counts: A Therapeutic Challenge

Cytomegalovirus (CMV) disease is a significant opportunistic infection (OI) among people living with HIV/AIDS (PLHIV) in advanced immunosuppression, particularly when CD4+ T-cell counts fall below 50 cells/mm³. Retinitis is its most common manifestation, followed by colitis and encephalitis. This report describes the case of a severely immunocompromised patient, whose clinical picture was shaped by a miscellany of signs and symptoms stemming both from systemic manifestations of CMV disease and from the clinical vulnerabilities inherent to advanced immunosuppression, as well as adverse events caused by potentially toxic drugs used in the therapeutic regimen. A 50-year-old cisgender man, PLHIV since 2014, with irregular ART use and persistently low CD4+ counts (< 30 cells/mm³), was hospitalized in January 2025 for neurotoxoplasmosis, without other OIs. Screening for tuberculosis, histoplasmosis, cryptococcosis, syphilis, and viral hepatitis was negative. In February, he was readmitted with CMV colitis and encephalitis, confirmed by molecular testing of the cerebrospinal fluid and colonic biopsies showing characteristic cytopathic effects, and was treated with ganciclovir. Ophthalmologic exam was initially normal. In May, he was hospitalized again with encephalopathy and dialysis-requiring acute kidney injury; CMV PCR in blood and CSF was negative, suggesting virologic response. However, in June he developed CMV retinitis, confirmed by fundoscopic examination. He also developed non-CMV-related complications and severe persistent pancytopenia attributed to ganciclovir. Despite reporting regular ART use since February, lack of immune recovery and CMV relapse suggested possible viral resistance. This case illustrates the therapeutic dilemmas involved in managing CMV infection in severely immunosuppressed patients. Overlapping clinical manifestations of CMV infection, drug toxicity, and poor immune recovery make management challenging. The severity of CMV involvement and the recurrence of infection are consistent with literature findings indicating that CMV is a particularly relevant opportunistic infection in the most severely immunocompromised patients, highlighting the importance of immune recovery through good adherence to ART and the monitoring of antiretroviral resistance in cases of suspected virological failure.