Acute Cytomegalovirus Infection Mimicking Atypical Preeclampsia and Complicated by Pulmonary Embolism in Late Pregnancy

Primary cytomegalovirus (CMV) infection during pregnancy is the most common congenital viral infection worldwide, yet maternal infection is often asymptomatic or presents with non-specific symptoms.In rare cases, acute CMV infection causes significant maternal hepatitis and systemic illness, closely resembling pregnancy-specific conditions such as preeclampsia or acute fatty liver of pregnancy (AFLP).Awareness of these atypical presentations is important to avoid unnecessary intervention while ensuring timely management of maternal and fetal complications.We report a 30-year-old gravida 2 para 1 woman who presented at 33 + 5 weeks' gestation with acute chest and shoulder pain.Initial investigations, including electrocardiography and computed tomography pulmonary angiography (CTPA), were unremarkable, apart from an isolated elevation in alanine aminotransferase (ALT), and she was discharged.Two days later, she re-presented with worsening chest pain, dyspnea, headache, pruritus, swollen hands, dark urine, pale stools, reduced appetite, abdominal discomfort, and proteinuria.Despite normal blood pressure, progressive respiratory compromise and persistently deranged liver function prompted further investigation.Repeat contrast-enhanced CT demonstrated small bilateral pulmonary emboli, and therapeutic low molecular weight heparin (LMWH) was commenced.Ongoing elevation of liver enzymes, oliguria, splenomegaly, proteinuria, headache, and evidence of mild fetal growth restriction raised concern for atypical preeclampsia despite persistent normotension.She received magnesium sulfate, antenatal corticosteroids, and close maternal and fetal surveillance, and delivery was initially planned within 24 hours.However, subsequent maternal improvement and positive CMV IgM serology prompted reconsideration of the diagnosis.Gastroenterology review attributed the liver dysfunction to acute CMV infection, and conservative multidisciplinary management was pursued.Following further monitoring and a subsequent brief admission for recurrent respiratory symptoms, labor was induced at 37 weeks of gestation, resulting in an uncomplicated vaginal delivery.The neonate tested positive for CMV with a very low viral load.The mother made a good recovery following transition from LMWH to apixaban postpartum.This case highlights the diagnostic complexity of acute CMV infection in late pregnancy, particularly when presenting with abnormal liver function tests, respiratory symptoms, and features suggestive of atypical preeclampsia.It also illustrates the rare coexistence of acute CMV infection and pulmonary embolism, emphasizing the need to consider multiple concurrent pathologies rather than attributing all clinical findings to a single diagnosis.Multidisciplinary collaboration, repeated clinical reassessment, and careful interpretation of evolving investigations were essential in avoiding unnecessary preterm delivery while ensuring maternal and fetal safety.