Cytomegalovirus (CMV) Central Nervous System Infection and Recurrent Posterior Circulation Ischemic Strokes in an Immunocompetent Patient.

Cytomegalovirus (CMV) infection in an immunocompetent adult is rarely symptomatic. Neurological manifestations are uncommon and are predominantly characterized by meningitis, myelitis, and acute polyradiculoneuritis. We report a rare case of an immunocompetent patient who presented with prolonged headaches complicated by recurrent posterior circulation ischemic strokes associated with intracranial stenoses of the basilar trunk and posterior cerebral arteries. Analysis of his cerebrospinal fluid (CSF) revealed lymphocytic meningitis with moderate elevation of the CSF protein level, normal CSF glucose level, and detection of the CMV genome by polymerase chain reaction (PCR). Viral load quantification showed high levels in both blood and CSF; serology was consistent with probable primary CMV infection. A comprehensive assessment ruled out any other causes of stroke. Treatment with ganciclovir was initiated, which led to normalization of the CSF; however, the clinical course was marked by the onset of meningeal hemorrhagic complications with triventricular hydrocephalus, followed by gastrointestinal and urinary hemorrhagic complications, which caused the death of the patient. Our case highlights the possibility of severe CMV central nervous system infection in immunocompetent individuals and the importance of considering testing for CMV in cases of persistent unexplained headaches accompanied by recurrent ischemic strokes, inflammatory CSF, or intracranial vasculopathy to avoid diagnostic and therapeutic delays, which can be fatal.