CYTOMEGALO-VIRUS PNEUMONIA IN BONE-MARROW TRANSPLANT RECIPIENTS - MILIARY AND DIFFUSE PATTERNS

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Abstract
Cytomegalovirus (CMV) pneumonia is a frequent complication of bone marrow transplantation. The clinical and pathologic features of 16 bone marrow transplant (BMT) recipients with histologic and/or cultural evidence of pulmonary CMV infections were reviewed. Two major morphologic patterns were observed. Five BMT recipients had a miliary pattern of pneumonia: multiple focal pulmonary lesions with extensive cytomegaly, often with localized necrobiosis, alveolar hemorrhage, fibrin deposition and a neutrophilic response. These patients had a fulminant onset of respiratory failure and at autopsy cytomegaly was evident in the spleen in all cases. Ten BMT recipients had interstitial pneumonitis with alveolar-cell hyperplasia, interstitial edema with mild to moderate lymphoid infiltrate and diffusely distributed cytomegalic cells. Their respiratory disease had an insidious onset and 2 of the patients recovered. Buffy-coat or bone-marrow cultures were positive for CMV in only 2 of 9 patients studied. Among the 8 autopsied, cytomegaly was not observed in the spleen. The 16th patient had cytomegaly present in the alveolar capillaries with minimal evidence of injury. These patterns of pneumonia were not related to a particular preparation protocol or to graft vs. host disease and were also observed in autopsies of non-BMT patients with CMV pneumonia. The miliary pattern of CMV pneumonia, which produces a sudden respiratory failure, results from a hematogenous seeding of the lungs from an extrapulmonary source. The pathogenesis of diffuse interstitial pneumonitis is less clear and may result from alveolar septal injury extending from a sublethal miliary pattern or possibly an activation of endogenous intrapulmonary virus.

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