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Reliable, easy-to-read patient information on common medical conditions — written in plain language, free of jargon, and grounded in current evidence. Browse the most frequent diagnoses, understand what they mean for everyday life, and learn which steps and questions help you have a focused conversation with your doctor.

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Cytomegalovirus infection differential diagnosis

Introduction

Overview

Overview

CMV infection can affect the eye, gastrointestinal tract and the central nervous system. Diagnosis of CMV requires differentiation of infections and diseases presenting with similar features. Majority of the patients with CMV end organ infection are immunosuppressed. Therefore CMV infection must be suspected in all the patients presenting with immunosuppression.

Differential Diagnosis of Cytomegalovirus infection

Differential Diagnosis of Cytomegalovirus infection

Cytomegalovirus Retinitis

Cytomegalovirus retinitis must be differentiated from tuberculosis, fungal infections, toxoplasmosis and syphilis:

Infectious Agent Clinical Manifestations
Cytomegalovirus
  • Physical evidence of a cytomegalovirus presence in one of both eyes will generally clinical present in the form of lesions, adjacent retinal vessels.
  • These lesions may impinge upon the fovea and the optic nerve. Furthermore they are usually discovered in close proximity to both.
  • Further extending lesions may be present in close proximity to the vortex veins as well as the ora serrata.[1]
Tuberculosis
Fungal

Candida albicans

Aspergillus fumigatus

  • Yellow subretinal infiltrates
  • Retinal infiltrates
  • Fungal hyphae are located throughout the eye – suggestive of pulmonary involvement[1]

Cryptococcus neoformans

Toxoplasmosis
  • Localized areas of infiltrate
  • Active lesions are adjacent to initial scarring[1]
Syphilis

Cytomegalovirus Colitis

The symptoms of colitis such as bloody diarrhea and abdominal pain are seen are seen in all forms of colitis. The table below differentiates among the common causes of colitis.[2][3] Cytomegalovirus colitis is diagnosed by demonstration of intranuclear inclusion bodies on colonic biopsy.

Diseases History and Symptoms Physical Examination Laboratory findings
Diarrhea Rectal bleeding Abdominal pain Atopy Dehydration Fever Hypotension Malnutrition Blood in stool (frank or occult) Microorganism in stool Pseudomembranes on endoscopy
Allergic Colitis + ++ + ++ ++
Chemical colitis + ++ ++ + + ++ +
Infectious colitis ++ ++ ++ +++ +++ ++ + ++ ++ +
Radiation colitis + ++ + + + ++
Ischemic colitis + + ++ + + + + ++
Drug-induced colitis + + ++ + ++ +

Neurologic Infection

Cytomegalovirus infection presents with confusion and altered mental status. It must be differentiated from other disorders presenting with similar features. The following table is a list of disorders and their differentiating features:

Diseases Symptoms Physical Examination Past medical history Diagnostic tests Other Findings
Headache ↓LOC Motor weakness Abnormal sensory Motor Deficit Sensory deficit Speech difficulty Gait abnormality Cranial nerves CT /MRI CSF Findings Gold standard test
Meningitis + – – – – + + – – History of fever and malaise – ↑ Leukocytes,

↑ Protein

↓ Glucose

CSF analysis[4] Fever, neck

rigidity

Cytomegalovirus ventriculoencephalitis + + +/- +/- – – + +/- + History of fever and malaise + ↑ Leukocytes, ↓ Glucose CSF PCR Fever, seizures, focal neurologic abnormalities
Brain tumor[5] + – – – + + + – + Weight loss, fatigue + Cancer cells[6] MRI Cachexia, gradual progression of symptoms
Hemorrhagic stroke + + + + + + + + – Hypertension + – CT scan without contrast[7][8] Neck stiffness
Subdural hemorrhage + + + + + – – – + Trauma, fall + Xanthochromia[9] CT scan without contrast[7][8] Confusion, dizziness, nausea, vomiting
Neurosyphilis[10][11] + – + + + + – + – STIs + ↑ Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[12]

Blindness, confusion, depression,

Abnormal gait

Complex or atypical migraine + – + + – – + – – Family history of migraine – – Clinical assesment Presence of aura, nausea, vomiting
Hypertensive encephalopathy + + – – – – + + – Hypertension + – Clinical assesment Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy – + – – – + + + + History of alcohal abuse – – Clinical assesment and lab findings Ophthalmoplegia, confusion
CNS abscess + + – – + + + – – History of drug abuse, endocarditis, immunosupression + ↑ leukocytes, ↓ glucose and ↑ protien MRI is more sensitive and specific High grade fever, fatigue,nausea, vomiting
Drug toxicity – + – + + + – + – – – – Drug screen test Lithium, Sedatives, phenytoin, carbamazepine
Metabolic disturbances (electrolyte imbalance, hypoglycemia) – + + + + + – – + – – Hypoglycemia, hypo and hypernatremia, hypo and hyperkalemia Depends on the cause Confusion, seizure, palpitations, sweating, dizziness, hypoglycemia
Multiple sclerosis exacerbation – – + + – + + + + History of relapses and remissions + ↑ CSF IgG levels

(monoclonal bands)

Clinical assesment and MRI [13] Blurry vision, urinary incontinence, fatigue

Differentiating cytomegalovirus infection in immunocompromised host

Cytomegalovirus infection is more common among immunocompromised patients who are at high risk for other fungal, bacterial, and viral infections. It should be differentiated from the following diseases:

Disease Differentiating signs and symptoms Differentiating tests
CNS lymphoma[14]
Disseminated tuberculosis[15]
Aspergillosis[16]
Cryptococcosis
Chagas disease[17]
CMV infection[18]
HSV infection[19]
Varicella Zoster infection[20]
Brain abscess[21][22]
Progressive multifocal leukoencephalopathy[23]
  • Symptoms are often more insidious in onset and progress over months. Symptoms include progressive weakness, poor coordination, with gradual slowing of mental function. Only seen in the immunosuppressed. Rarely associated with fever or other systemic symptoms
References

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Infectious Retinitis: A Review. YACHNA AHUJA, MD · STEVEN M. COUCH, MD · RAYMUND R. RAZONABLE, MD · SOPHIE J. BAKRI, MD. http://www.retinalphysician.com/articleviewer.aspx?articleID=102293. Accessed April 13, 2016.
  2. ↑ Thielman NM, Guerrant RL (2004). “Clinical practice. Acute infectious diarrhea”. N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
  3. ↑ Khan AM, Faruque AS, Hossain MS, Sattar S, Fuchs GJ, Salam MA (2004). “Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study”. J Trop Pediatr. 50 (6): 354–6. doi:10.1093/tropej/50.6.354. PMID 15537721.
  4. ↑ Carbonnelle E (2009). “[Laboratory diagnosis of bacterial meningitis: usefulness of various tests for the determination of the etiological agent]”. Med Mal Infect. 39 (7–8): 581–605. doi:10.1016/j.medmal.2009.02.017. PMID 19398286.
  5. ↑ Morgenstern LB, Frankowski RF (1999). “Brain tumor masquerading as stroke”. J Neurooncol. 44 (1): 47–52. PMID 10582668.
  6. ↑ Weston CL, Glantz MJ, Connor JR (2011). “Detection of cancer cells in the cerebrospinal fluid: current methods and future directions”. Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
  7. ↑ 7.0 7.1 Birenbaum D, Bancroft LW, Felsberg GJ (2011). “Imaging in acute stroke”. West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  8. ↑ 8.0 8.1 DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). “ACR Appropriateness Criteria® on cerebrovascular disease”. J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
  9. ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). “Cerebrospinal fluid in cerebral hemorrhage and infarction”. Stroke. 6 (6): 638–41. PMID 1198628.
  10. ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). “Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients”. J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
  11. ↑ Berger JR, Dean D (2014). “Neurosyphilis”. Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  12. ↑ Ho EL, Marra CM (2012). “Treponemal tests for neurosyphilis–less accurate than what we thought?”. Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
  13. ↑ Giang DW, Grow VM, Mooney C, Mushlin AI, Goodman AD, Mattson DH; et al. (1994). “Clinical diagnosis of multiple sclerosis. The impact of magnetic resonance imaging and ancillary testing. Rochester-Toronto Magnetic Resonance Study Group”. Arch Neurol. 51 (1): 61–6. PMID 8274111.
  14. ↑ Gerstner ER, Batchelor TT (2010). “Primary central nervous system lymphoma”. Arch. Neurol. 67 (3): 291–7. doi:10.1001/archneurol.2010.3. PMID 20212226.
  15. ↑ von Reyn CF, Kimambo S, Mtei L, Arbeit RD, Maro I, Bakari M, Matee M, Lahey T, Adams LV, Black W, Mackenzie T, Lyimo J, Tvaroha S, Waddell R, Kreiswirth B, Horsburgh CR, Pallangyo K (2011). “Disseminated tuberculosis in human immunodeficiency virus infection: ineffective immunity, polyclonal disease and high mortality”. Int. J. Tuberc. Lung Dis. 15 (8): 1087–92. doi:10.5588/ijtld.10.0517. PMID 21740673.
  16. ↑ Latgé JP (1999). “Aspergillus fumigatus and aspergillosis”. Clin. Microbiol. Rev. 12 (2): 310–50. PMC 88920. PMID 10194462.
  17. ↑ Rassi A, Rassi A, Marin-Neto JA (2010). “Chagas disease”. Lancet. 375 (9723): 1388–402. doi:10.1016/S0140-6736(10)60061-X. PMID 20399979.
  18. ↑ Emery VC (2001). “Investigation of CMV disease in immunocompromised patients”. J. Clin. Pathol. 54 (2): 84–8. PMC 1731357. PMID 11215290.
  19. ↑ Bustamante CI, Wade JC (1991). “Herpes simplex virus infection in the immunocompromised cancer patient”. J. Clin. Oncol. 9 (10): 1903–15. doi:10.1200/JCO.1991.9.10.1903. PMID 1919640.
  20. ↑ Hambleton S (2005). “Chickenpox”. Curr. Opin. Infect. Dis. 18 (3): 235–40. PMID 15864101.
  21. ↑ Alvis Miranda H, Castellar-Leones SM, Elzain MA, Moscote-Salazar LR (2013). “Brain abscess: Current management”. J Neurosci Rural Pract. 4 (Suppl 1): S67–81. doi:10.4103/0976-3147.116472. PMC 3808066. PMID 24174804.
  22. ↑ Patel K, Clifford DB (2014). “Bacterial brain abscess”. Neurohospitalist. 4 (4): 196–204. doi:10.1177/1941874414540684. PMC 4212419. PMID 25360205.
  23. ↑ Tan CS, Koralnik IJ (2010). “Progressive multifocal leukoencephalopathy and other disorders caused by JC virus: clinical features and pathogenesis”. Lancet Neurol. 9 (4): 425–37. doi:10.1016/S1474-4422(10)70040-5. PMC 2880524. PMID 20298966.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]