S5401 Acute on Chronic Liver Injury Due to Cytomegalovirus Infection in a Non-Transplant Patient

Introduction: Cytomegalovirus (CMV) is a common β-herpesvirus and a well-known opportunistic pathogen, characteristically associated with inflammation in patients undergoing organ or stem cell transplantation. We describe an interesting case of CMV infection in a patient with chronic liver disease, but with no prior history of organ transplantation. Case Description/Methods: We report the case of 57-year-old African American woman with history of cirrhosis secondary to autoimmune hepatitis (AIH), who presents with new onset encephalopathy and anasarca. Outpatient liver enzymes 5 months prior were slightly elevated with aspartate aminotransferase (AST) 103, alanine aminotransferase (ALT) 77, alkaline phosphatase (ALP) 149, and TBil 2.0. Lab work on arrival was notable for mild leukocytosis (12.4 K/uL) with further elevation in Liver Enzymes to AST 222, ALT 191, ALP 173, and TBil 10 with DBil 4.7. She denies recent infectious or gastrointestinal symptoms, alcohol use, or new supplements or medications. She was previously on mycophenolate 500 twice daily and prednisone 10 mg for AIH, which were discontinued 1 year and 6 months prior, respectively. Workup otherwise negative for acute hepatitis and spontaneous bacterial peritonitis on paracentesis. Decompensation was attributed to AIH flare and she was subsequently initiated on intravenous solumedrol 30 3-times daily. However, patient continued to decline clinically with up trending liver enzymes. One week following admission, infectious workup was expanded to viral etiologies and she was found to be IgG positive for cytomegalovirus (CMV) with DNA quant 21,634 IU/mL, confirming CMV viremia. She was started on valganciclovir with tapering of steroids. The patient continued to worsen in spite of this intervention and passed away from overwhelming infection with multi-organ failure. Discussion: This case highlights the importance of early infectious screening in AIH patients with elevated liver enzymes, particularly for CMV, which is often overlooked outside of transplant settings. While immunosuppression improves outcomes in select AIH patients, glucocorticoids independently increase CMV risk. In this case, CMV viremia was detected after clinical decline despite steroid therapy, which may have in fact precipitated worse outcomes. This underscores the importance of vigilance for viral reactivation in liver failure, optimizing management strategies, and refining immunosuppression decisions to mitigate risks and improve patient outcomes.