1 case of cytomegalovirus infection causing DIC in children

preface

Human cytomegalovirus (HCMV) infection is extremely widespread in China, with a positive antibody rate of 60% to 80% in infancy and early childhood, and primary infections occur mostly in infancy and early childhood [1].

HCMV is a weak pathogenic factor, which is not obviously pathogenic to immunocompetent individuals, and the vast majority of them are manifested as asymptomatic infections; However, it may cause serious illness
in people with pathological and physiological immunocompromise.

Case passed

The child, male, 1 month and 1 day, was admitted to the hospital due to the main complaint of "fever for 8 hours", and the admission diagnosis was:

1.
Sepsis
.
Diagnostic basis: the child has fever, the peak > 38.
5 °C, the heart rate increases by 180 times per minute, the capillary refill time is >> 3 seconds, the presence of hypoxemia, and the increase in CRP and PCT;

2.
Fever to be treated
.
1) Acute upper respiratory tract infection? Basis of diagnosis: fever in children; Physical examination: slightly red throat, no abnormal discharge is
seen.
2) Bloodstream infection? Diagnostic basis: fever, examination except pharyngeal infrared, no other positive signs; White blood cell count, inflammatory indicators CRP and PCT were all elevated, suggesting infection, and blood culture was tracked for co-diagnosis;

3.
Hypoxemia
.
Diagnostic basis: capillary refill time >3 seconds, PO2 51.
8 mmHg;

4.
Abnormal
liver function.
Diagnostic basis: Mild yellowing of the skin of the whole body, ALT 295.
3 U/L, AST 747.
1U/L, TBI 74.
3 μmol/L, DBI 37.
5 μmol/L
.

1.
Current medical history: about 8 hours ago, the child had fever after a cold, body temperature 37.
8 °C, no rash, chills and convulsions, the family gave physical cooling body temperature can be reduced, easy to repeat, on July 21, 2022 to our hospital pediatric fever clinic for treatment, as "fever to be checked" hospitalization
.

2.
Physical examination: T 39.
4 °C, P 146 times/min, R 42 times/min, BP 78/42mmHg
.
Clear-minded, spiritually able
.
The skin of the limbs is patterned and cold
.
Breathe steadily
.
There is no edema on the eyelids
.
Red lips, smooth oral mucosa, slightly red throat, no abnormal discharge
seen.
Cardiac and pulmonary examinations did not reveal abnormalities
.
The abdomen is flat and soft, the whole abdomen has no tenderness and rebound pain, and the bowel sounds are 5 times per minute
.
There is no edema
on both lower extremities.
There is no redness in the urethral opening, and no abnormal discharge is
seen.
Capillary refill time > 3 seconds
.

3.
Auxiliary examination: blood routine results: WBC 11.
4×109/L, RBC 3.
4×109/L, PLT 116×109/L
.
Hypersensitivity CRP 18.
08mg/L, PCT 0.
89ng/ml
.
Hepatic function: ALT 295.
3U/L, AST 747.
1U/L, TBI 74.
3umol/L, DBI 37.
5umol/L
.
Coagulation results: PT 9.
9s, APTT 30.
7s, TT 17.
6s, Fbg 1.
78g/L, D dimer 24.
34mg/L, see Table 1
.
Blood gas analysis: PH

7.
485，PCO2 27.
8mmHg，PO2 51.
8mmHg

4.

Additional diagnosis: 1) Cytomegalovirus infection
.

On July 23, the new appearance of the child's lower limbs was scattered at the bleeding point, and he still had repeated fever, the heat peak was 39 ° C, and the limbs were cold and patterned during the rising body temperature; Urgent blood routine and coagulation program exclude the possibility of DIC
.

According to the International Society for Thrombotic and Hemostatic (ISTH) overt DIC scoring criteria [2], the child scored >5 points, and the diagnosis of DIC was confirmed
.

Table 1 Changes in test indicators in children

Figure 1 Blood, urine and breast cytomegalovirus DNA results

Figure 2 TAT and PIC test results of the child

Case studies

Clinical case studies

The diagnosis of cytomegalovirus infection was confirmed by the human milk pathway, which was a symptomatic infection according to the clinical signs, and the lesions were mainly concentrated in the liver, causing HCMV hepatitis
.

Inspection case studies

(1) The child's blood, urine and breast cytomegalovirus DNA on the second day of admission were all positive, and it was confirmed that the cytomegalovirus infection caused abnormal liver function
.

(2) The liver damage of the child is serious and changes rapidly, and the AST and ALT are 7-10 times
higher on the 3rd day of admission than on the 1st day.

(3) The child's condition is urgent, the new lower limbs of the two lower limbs are scattered at the bleeding point on the 3rd day of admission, the DIC is highly suspected, and the blood routine of urgent blood investigation and coagulation items are verified
.

(4) According to the results of the coagulation molecular markers TAT and PIC, it is suggested that thrombotic DIC is recommended, and it is recommended to carry out anticoagulation and vascular endothelial protection therapy
as soon as possible.

Knowledge development

Human cytomegalovirus infection is extremely widespread in China, and the positive rate of HCMV antibodies in the general population is 86% to 96%, pregnant women are about 95%, and 60% to 80%
in infancy and early childhood.

The cellular affinity of HCMV is very extensive: (1) epithelial cells, endothelial cells and fibroblasts are the main target cells; (2) Peripheral blood white blood cells are susceptible cells; (3) Special parenchymal cells such as nerve cells of the brain and retina, smooth muscle cells of the gastrointestinal tract and liver cells can also be infected
.

Case summary

The mother of the child is infected with cytomegalovirus during pregnancy, but does not pay enough attention to the dynamic monitoring of cytomegalovirus replication in vivo; This leads to the child's infection with cytomegalovirus through the breastfeeding pathway, causing HCMV hepatitis, accompanied by severe liver damage, and the combination of other diseases leading to the occurrence of
DIC.

Expert reviews

The child was infected with cytomegalovirus through the breast milk pathway to cause hepatitis, which further induced DIC, which is a rare clinical case
.

References

[1] Infectious Disease Group of Pediatrics Branch of Chinese Medical Association, National Pediatric Clinical Viral Infection Collaboration Group, Editorial Board of Chinese Journal of Pediatrics.

[2] TAYLORF B J， TOH C H， HOOTS W K， et al.

[SONG Jing-chun,ZHANG Wei,ZHANG Lei,et al.
Chinese expert consensus on standardized assessment of coagulation dysfunction in severely ill patients[J].
PLA Medical Journal,2022, 47(2): 11.