Cytomegalovirus infection following pulse therapy in systemic lupus erythematosus

A case of cytomegalovirus (CMV) infection following pulse therapy in systemic lupus erythematosus (SLE) is reported. A 39-year-old woman developed polyarthralgia and fever during her second pregnancy at the age of 29. Alopecia, Raynaud's phenomenon and malar erythema developed later. She was admitted to another hospital in January 1982 because of polyarthralgia. Laboratory examination showed positive antinuclear antibody, high titers of anti-DNA antibody, leukopenia and telescoped urinary sediments. She was diagnosed as SLE and was treated with prednisolone 40mg/day. Polyarthralgia and malar erythema disappeared, but telescoped sediments remained unchanged. She was transferred to this hospital in April 1982 for the purpose of renal biopsy. Laboratory findings on admission were as follows: the whitecell count 3, 800, CRP 1+, the erythrocyte sedimentation rate 97mm per hour, RA test negative, antinuclear antibody positive, anti-DNA antibody 805U/ml (RIA), anti-RNP, Sm, SS-B antibodies negative, anti-SS-A antibody 1:16, CH50 13.6U/ml, C3 33mg/dl, C4 9mg/dl, and circulating immune complex 20.0ug/ml (Clq binding). 24-hour urinary protein was 1.3 g/day, and urinalysis revealed 13-15 white blood cells, 12-13 red blood cells, 10-13 granular casts and 1-2 hyaline casts per field. The creatinine clearance was 91ml/min. Renal biopsy showed active diffuse proliferative lupus nephritis. She was treated with prednisolone 60mg/day, but telescoped sediments were unchanged. Pulse therapy was porformed twice with methylprednisolone 1g/day for three days in August. In September, anti-DNA antibody and serum complement were almost normal. Velcro rales became audible in both lung bases and arterial blood gas values worsened. Interstitial pneumonitis due to SLE was suspected and prednisolone was increased to 100mg/day. Immunosuppressive drugs and plasmapheresis were added. The titer of antibody to CMV (complement fixation) rose from 1:16 in April to 1:128 in September. Urine culture for CMV performed in September was reported as positive in October. Prednisolone was tapered. Blood gases improved. In February 1983, ulcers of stomach and tongue developed. The histological examination revealed cytomegalic inclusion bodies. Lung biopsy was not performed. CMV infection is rare in adults and reported mostly in patients with organ transplants and neoplasms, who usually received corticosteroids or immunosuppressive drugs and were severely immunocompromised. CMV infection in adults is th