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LETTER TO EDITOR  
Year : 2012  |  Volume : 55  |  Issue : 4  |  Page : 611-613
Cytomegalovirus pneumonia in a neonate presenting as a space occupying lesion mimicking a tumor


1 Department of Pathology, St. John's Medical College, Bangalore, India
2 Department of Pediatric Surgery, Narayana Hrudayalaya, Bangalore, India

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Date of Web Publication4-Mar-2013
 

How to cite this article:
Rao BK, Correa MM, Rao S. Cytomegalovirus pneumonia in a neonate presenting as a space occupying lesion mimicking a tumor. Indian J Pathol Microbiol 2012;55:611-3

How to cite this URL:
Rao BK, Correa MM, Rao S. Cytomegalovirus pneumonia in a neonate presenting as a space occupying lesion mimicking a tumor. Indian J Pathol Microbiol [serial online] 2012 [cited 2017 Dec 16];55:611-3. Available from: http://www.ijpmonline.org/text.asp?2012/55/4/611/107866


Sir,

Space occupying solid lesions in the lungs of neonates are due to congenital malformations or rare neoplasms. [1] We share our experience with a 2-week-old neonate presenting with lower respiratory tract infection and a mass that was radiologically suggestive of a lung tumor. Histopathology of the lobectomy performed showed cytomegalovirus (CMV) pneumonia.

A 2-week-old female neonate presented with lower respiratory tract infection. Chest radiograph and subsequent computed tomography (CT) [Figure 1] showed a large solid mass in the upper left thorax, completely replacing the left upper lobe, highly suggestive of a tumor. All five bronchopulmonary segments were involved by the lesion. The infant was taken up for surgery and upper lobectomy was performed. Per-operatively, this lobe appeared solid. The pleura of the inferior surface was eroded with underlying unhealthy lung.
Figure 1: Computed tomography scan images showing a solid lesion occupying the region of the upper lobe of the left lung (arrows)

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Grossly, the lobe measured 6.0 × 2.5 × 1.5 cm and the inferior surface was covered by exudate. The cut surface showed no mass lesion. Hematoxylin and eosin stained sections surprisingly showed no tumor, but extensive areas of consolidation with numerous histiocytic giant cells [Figure 2]. Some of the alveolar spaces were lined by large cells containing homogenous dark purple viral inclusion bodies, surrounded by a characteristic halo, suggestive of CMV infection [Figure 3]. The Periodic acid Schiff (PAS) and Gomori's methanamine silver (GMS) stains were negative for fungal organisms.
Figure 2: Low - power view of the lung showing alveolar exudate. (Haematoxylin & Eosin ×100 )

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Figure 3: Cytomegaly of the cells lining the alveolus with the characteristic haloed viral inclusion shown by the arrow (Haematoxylin & Eosin, ×400)

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Subsequent toxoplasma, rubella, CMV and herpes (TORCH) titers for IgM and IgG antibodies against CMV were positive in both mother and child. Fundoscopy examination of the child was normal. The infant had an uneventful and speedy recovery without anti-viral therapy, and was doing well after 6 months.

The differential diagnoses for space occupying lesions of the lung in neonates are congenital tumors, such as teratomas and neuroblastomas, and congenital airway malformations, such as pulmonary airway malformations. Presentation in these cases can be antenatal, as a lower respiratory infection or as respiratory distress. Investigations include imaging with X-rays and computed tomography (CT) scan thorax. Most of the congenital lesions have a predominantly cystic appearance; the exceptions of a more solid process are the type 3 congenital cystic pulmonary airway malformations. [1] Treatment is surgical excision (usually a lobectomy) if feasible, or a biopsy if excision is not feasible.

In this patient, the radiographic findings of a single space occupying solid appearing lesion were worrisome for a tumor, for which reason thoracotomy and lobectomy were performed. Subsequent histopathology showed CMV pneumonia.

Neonatal pneumonia of early onset is most commonly caused by ascending infection from the maternal genital tract across the membranes and occurs in the 1 st week. Gram-negative bacteria mainly  Escherichia More Details coli and Klebsiella predominate and the baby is often septicemic at birth. Late onset pneumonia is usually caused by nosocomial infection. Two Indian studies found Streptococcus pneumonia and Staphylococcus aureus to be the most common causes. Systemic infection in the mother, such as Rubella, CMV, Treponema pallidum, Listeria monocytogenes, tuberculosis, and human immunodeficiency virus may cause intrauterine pneumonia. These infections may be asymptomatic in the mother as in the present case. Occasionally, the cause is "auto-infection" from maternal organisms that colonized the infant at birth such as Mycoplasma sp., Chlamydia trachomatis, Pneumocystis jirovecii, and viruses. Congenital syphilis is an important cause in developing countries. [2]

One percent of all newborns are infected with CMV. Prenatal infection is transplacental and perinatal infection is acquired by exposure to infected cervical secretions, breast milk, or blood products. Most exposed term infants are asymptomatic or not infected. CMV pneumonia is known to occur in immunocompromised children. [3],[4],[5]

Chest radiography is the first line of investigation and changes in immunocompromised individuals with pneumonia have been well documented. These are usually multiple nodules less than 5 mm in diameter, or diffuse infiltrates. CT findings comprise areas of ground-glass attenuation, dense consolidation in interstitial pneumonia, and micronodules. [6]

Although there are reports of cavitary pneumonia due to CMV, space occupying lesions mimicking tumor as encountered in this case have not been described in the neonatal period. CMV pneumonia has been documented only rarely in immunocompetent patients, that too adults. [1] Search of literature yielded one adult male aged 47 years with a cavitary mass of the left upper lobe, mimicking a tumor. In this case also, thoracotomy and wedge excision of the mass showed histological features of CMV pneumonia. [3] Single space occupying lesions in immunocompromised adults, one of which mimicked lung carcinoma, and multiple cavitating masses in patients with acquired immune deficiency syndrome have been reported.

In contrast to these cases, our patient is a neonate, and did not have a risk factor or evidence of an immunocompromised state. To our knowledge, this is the only neonate with CMV pneumonia presenting with a mass lesion in the lung.

CMV pneumonia thus should be a differential diagnosis when a neonate has a space occupying lesion in the lung. Such patients must be investigated for CMV by serology for IgM antibodies, which is the best diagnostic test. [3] Unnecessary surgical procedures with inevitable complications can thus be avoided. Symptomatic neonates with CMV infection have a mortality rate of upto 30% and 70-90% of survivors have neurological impairment, including hearing loss, mental retardation, and visual disturbances. Close monitoring of these patients is hence required to identify these deficits, especially hearing defects.

 
   References Top

1.Dishop MK, McKay EM, Kreiger PA, Priest JR, Williams GM, Langston C, et al. Fetal lung interstitial tumor (FLIT): A proposed newly recognized lung tumor of infancy to be differentiated from cystic pleuropulmonary blastoma and other developmental pulmonary lesions. Am J Surg Pathol 2010;34:1762-72.  Back to cited text no. 1
[PUBMED]    
2.Duke T. Neonatal pneumonia in developing countries. Arch Dis Child Fetal Neonatal Ed 2005;90:F211-9.  Back to cited text no. 2
[PUBMED]    
3.Karakelides H, Aubry MC, Ryu JH. Cytomegalovirus pneumonia mimicking lung cancer in an immunocompetent host. Mayo Clin Proc 2003;78:488-90.  Back to cited text no. 3
[PUBMED]    
4.Taylor GH. Cytomegalovirus. Am Fam Physician 2003;67:519-24.  Back to cited text no. 4
[PUBMED]    
5.Demmler GJ, Cherry J, Kaplan SL. Cytomegalovirus. In: Feigin RD, Cherry J, Kaplan SL, Demmler-Harrison GJ, editors. Feigin and Cherry. Text Book of Pediatric Infectious Diseases. 6 th ed., vol. 1. Philadelphia: WB Saunders; 2009. p. 1912-32.  Back to cited text no. 5
    
6.Franquet T, Lee KS, Müller NL. Thin-section CT findings in 32 immunocompromised patients with cytomegalovirus pneumonia who do not have AIDS. AJR Am J Roentgenol 2003;181:1059-63.  Back to cited text no. 6
    

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Correspondence Address:
Bhanumati K Rao
Department of Pathology, St. John's Medical College, Sarjapur Road, Bangalore - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.107866

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