Disseminated Coinfections of Cytomegalovirus and Herpes Simplex Virus in Lupus Nephritis

Introduction: Cytomegalovirus (CMV) and herpes simplex virus (HSV) are ubiquitous virus in general population, but these viruses are critical pathogen in immunocompromised patients, particularly with HIV. We report a case of disseminated coinfections of CMV and HSV in patient without HIV. Case Description: A 57-year-old woman visited hospital due to renal dysfunction. She had preeclampsia during first pregnancy about 30 years ago and underwent steroid therapy due to nephrotic syndrome. After that time, renal function has been stable. Laboratory findings revealed MDRD-eGFR 19.0 ml/min/1.73m2, anti-dsDNA titer 88 IU/mL and decreased complement level. In the renal biopsy findings, lupus nephritis Class IV-G was confirmed, and then methylprednisolone and cyclophosphamide were administered. After second cyclophosphamide administration, she had fever and dyspepsia. In gastrointestinal endoscopy findings, multiple patches-like lesions and ulceration with a geographic shape were observed in the antrum with immunohistochemically staining showing CMV. Esophageal ulceration with feature such as molding of nuclear contours, margination of chromatin to the periphery of nuclei was consistent with HSV esophagitis. She suddenly developed a confused mentality, and brain MRI revealed regional patchy high signal on diffusion-weighted images and fluid-attenuated inversion recovery images at the right temporal-occipital white matter. In the CSF analysis, CMV PCR positivity was confirmed. Finally, serum CMV real time-PCR revealed 1.71*106 copies/mL, and HSV type 1 PCR positive finding was observed. Ganciclovir and foscarnet were administered for the disseminated coinfections of CMV and HSV type 1. After administering for 8 weeks, she was successfully recovered. After discharge, SLE activity maintained stable, and she underwent hemodialysis for end-stage kidney disease. Discussion: It is essential to consider the possibility of multiple opportunistic coinfections in patients suspected of being immunocompromised, even if patients are HIV negative.