CRITICAL CARE - ADULTS / REVIEW ARTICLE
CMV and HHV-6 reactivation in immunocompetent patients hospitalised in the ICU – is it a real problem? A case series and narrative review
 
More details
Hide details
1
Department of Anaesthesiology and Intensive Care, 4th Military Clinical Hospital in Wroclaw, Poland
 
2
Clinical Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
 
 
Submission date: 2025-06-24
 
 
Final revision date: 2026-05-18
 
 
Acceptance date: 2026-07-27
 
 
Publication date: 2026-08-19
 
 
Corresponding author
Agnieszka Wieczorek   

Department of Anesthesiology and Intensive Care, 4th Military Clinical Hospital in Wroclaw, 5 Rudolfa Weigla St., 50-981 Wroclaw, Poland
 
 
Anaesthesiol Intensive Ther 2026;58(1):189-197
 
KEYWORDS
TOPICS
ABSTRACT
Cytomegalovirus (CMV) and human herpesvirus-6 (HHV-6) infections typically follow a benign course in immunocompetent individuals. However, critically ill patients may develop profound immune dysregulation associated with sepsis, trauma, prolonged mechanical ventilation, or immunomodulatory therapy, which may predispose them to reactivation of latent viruses. A growing body of evidence suggests that CMV reactivation in immunocompetent, critically ill patients is associated with adverse clinical outcomes, including prolonged mechanical ventilation, longer ICU stay, and an increased risk of secondary infections. The clinical significance of herpesvirus reactivation in this population remains incompletely defined, and diagnosis may be challenging due to nonspecific clinical presentation and limited availability of molecular diagnostics. The aim of this study was to present a case series of CMV and HHV-6 reactivation in immunocompetent, critically ill patients and to discuss diagnostic and therapeutic challenges in the context of current literature. We describe three critically ill patients who developed herpesvirus reactivation during hospitalisation. One patient presented with clinically significant CMV reactivation suspected to contribute to gastrointestinal and pulmonary manifestations in the setting of rising CMV DNAemia. Another patient was diagnosed with CMV-associated immune thrombocytopaenia. A third patient developed rapidly progressive neurological deterioration with cerebrospinal fluid pleocytosis and HHV-6 DNA detected in cerebrospinal fluid, consistent with suspected HHV-6-associated encephalitis. Herpesvirus reactivation may be considered in critically ill patients with unexplained clinical deterioration despite the absence of classical immunosuppression.
REFERENCES (28)
1.
Mostel Z, Perl A, Marck M, Mehdi SF, Lowell B, Bathija S, et al. Post-sepsis syndrome – an evolving entity that afflicts survivors of sepsis. Mol Med 2020; 26: 6. DOI: 10.1186/s10020-019-0132-z.
 
2.
Mira JC, Gentile LF, Mathias BJ, Efron PA, Brakenridge SC, Mohr AM, et al. Sepsis pathophysiology, chronic critical illness, and PICS. Crit Care Med 2017; 45: 253–262. DOI: 10.1097/CCM.0000000000002074.
 
3.
Lambe G, Mansukhani D, Khodaiji S, Shetty A, Rodrigues C, Kapadia F. Immune modulation and cytomegalovirus reactivation in sepsis-induced immunosuppression: a pilot study. Indian J Crit Care Med 2022; 26: 53-61. DOI: 10.5005/jp-journals-10071-24079.
 
4.
Li X, Huang Y, Xu Z, Zhang R, Liu X, Li Y, Mao P. Cytomegalovirus infection and outcome in immunocompetent patients in the intensive care unit: a systematic review and meta-analysis. BMC Infect Dis 2018; 18: 289. DOI: 10.1186/s12879-018-3195-5.
 
5.
Limaye AP, Kirby KA, Gordon DR, Leisenring WM, Bulger EM, Neff MJ, et al. Cytomegalovirus reactivation in critically ill immunocompetent patients. JAMA 2008; 300: 413-422. DOI: 10.1001/jama.300.4.413.
 
6.
Bhide M, Singh O, Nasa P, Juneja D. Cytomegalovirus infection in non-immunocompromised critically ill patients: a management perspective. World J Virol 2024; 13: 89135. DOI: 10.5501/wjv.v13.i1.89135.
 
7.
Osawa R, Wagener M, Singh N. Cytomegalovirus infection in patients with sepsis due to bloodstream infections: lower risk and better outcomes in new vs already hospitalised intensive care unit admissions. Anaesth Intensive Care 2016; 44: 571–580. DOI: 10.1177/0310057-X1604400514.
 
8.
Ljungman P, Chemaly RF, Khawaya F, Alain S, Avery R, Badshah C, et al. Consensus definitions of cytomegalovirus infection and disease in transplant patients including resistant and refractory CMV for use in clinical trials: 2024 update. Clin Infect Dis 2024; 79: 787–794. DOI: 10.1093/cid/ciae321.
 
9.
Papazian L, Fraisse A, Garbe L, Zandotti C, Thomas P, Saux P, et al. Cytomegalovirus: an unexpected cause of ventilator-associated pneumonia. Anesthesiology 1996; 84: 280-287. DOI: 10.1097/00000542-199602000-00005.
 
10.
Stephan F, Meharzi D, Ricci S, Fajac A, Clergue F, Bernaudin JF. Eva­luation by polymerase chain reaction of cytomegalovirus reactivation in intensive care patients under mechanical ventilation. Intensive Care Med 1996; 22: 1244-1249. DOI: 10.1007/BF01709343.
 
11.
Imlay H, Limaye AP. Current understanding of cytomegalovirus reactivation in critical illness. J Infect Dis 2020; 221 (Suppl 1): S94-S102. DOI: 10.1093/infdis/jiz638.
 
12.
Cowley NJ, Owen A, Shiels SC, Millar J, Woolley R, Ives N, et al. Safety and efficacy of antiviral therapy for prevention of cytomegalovirus reactivation in immunocompetent critically ill patients: a randomized clinical trial. JAMA Intern Med 2017; 177: 774-783. DOI: 10.1001/jamainternmed.2017.0895.
 
13.
Limaye AP, Stapleton RD, Peng L, Gunn SR, Kimball LE, Hyzy R, et al. Effect of ganciclovir on IL-6 levels among cytomegalovirus-seropositive adults with critical illness: a randomized clinical trial. JAMA 2017; 318: 731-740. DOI: 10.1001/jama.2017.10569.
 
14.
Chia XT, Wong HLM, Loh JS. Human herpesvirus-6 infection in a critically ill and immunocompetent patient: a case report. J Med Case Rep 2024; 18: 81. DOI: 10.1186/s13256-024-04387-5.
 
15.
Berzero G, Campanini G, Vegezzi E, Paoletti M, Pichiecchio A, Simon­celli AM, et al. Human herpesvirus-6 encephalitis in immunocompetent and immunocompromised hosts. Neurol Neuroimmunol Neuroinflamm 2021; 8: e948. DOI: 10.1212/NXI.0000000000000948.
 
16.
Pokorska-Śpiewak M, Niezgoda A, Gołkowska M, Czech-Kowalska J, Gruszfeld D, Dobrzańska A, et al. Recommendations on the diagnosis and treatment of CMV infections. Przegl Epidemiol 2016; 70: 297-310.
 
17.
Yoon J, Lee J, Kim DS, Lee JW, Hong SW, Hwang HW, et al. Endo­scopic features and clinical outcomes of cytomegalovirus gastroenterocolitis in immunocompetent patients. Sci Rep 2021; 11: 6284. DOI: 10.1038/s41598-021-85845-8.
 
18.
Bonnet F, Morlat P, Neau D, Viallard JF, Ragnaud JM, Dupon M, et al. Hematologic and immunologic manifestations of primary cyto­megalovirus infection in non-immunocompromised hospitalized adults. Rev Med Interne 2000; 21: 586–594. DOI: 10.1016/s0248-8663(00)80003-x [Article in French].
 
19.
Sherman S, Eytan O, Justo D. Thrombosis associated with acute cyto­megalovirus infection: a narrative review. Arch Med Sci 2014; 10: 1186-1190. DOI: 10.5114/aoms.2014.47828.
 
20.
Boeckh M. Ganciclovir to prevent reactivation of cytomegalovirus in patients with acute respiratory failure and sepsis. ClinicalTrials.gov identifier: NCT04706507.
 
21.
Essegian DJ, Sibley RA. Cytomegalovirus-related immune thrombocytopenic purpura in an immunocompetent adult. AIM Clin Cases 2024; 3: e231089. DOI: 10.7326/aimcc.2023.1089.
 
22.
Neunert C, Terrell DR, Arnold DM, Buchanan G, Cines DB, Cooper N, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv 2019; 3: 3829-3866. DOI: 10.1182/bloodadvances.2019000966.
 
23.
DiMaggio D, Anderson A, Bussel JB. Cytomegalovirus can make immune thrombocytopenic purpura refractory. Br J Haematol 2009; 146: 104-112. DOI: 10.1111/j.1365-2141.2009.07714.x.
 
24.
Shragai T, Lebel E, Deshet D, Varon D, Avivi I, Kirgner I, et al. Charac­teristics and outcomes of adults with cytomegalovirus-associated thrombocytopenia: a case series and literature review. Br J Haematol 2020; 191: 863-867. DOI: 10.1111/bjh.17017.
 
25.
Singh N, Paterson DL. Encephalitis caused by human herpesvirus-6 in transplant recipients: relevance of a novel neurotropic virus. Transplantation 2000; 69: 2474-2479. DOI: 10.1097/00007890-200006270-00002.
 
26.
Seeley WW, Marty FM, Holmes TM, Upchurch K, Soiffer RJ, Antin JH, et al. Post-transplant acute limbic encephalitis: clinical features and relationships to HHV-6. Neurology 2007; 69: 156-165. DOI: 10.1212/01.wnl.0000265591.10200.d7.
 
27.
Traube CH, Bloch KC, Myers JW, Moorman JP. Case report and lite­rature review: HHV-6 associated meningoencephalitis in an immunocompetent adult. Herpes 2008; 15: 33-35.
 
28.
Bhanushali MJ, Kranick SM, Freeman AF, Cuellar-Rodriguez JM, Battiwalla M, Gea-Banacloche JC, et al. Human herpesvirus-6 encephalitis complicating allogeneic hematopoietic stem cell transplantation. Neurology 2013; 80: 1494-1500. DOI: 10.1212/WNL.0b013e31828cf8a2.
 
eISSN:1731-2531
ISSN:1642-5758
Journals System - logo
Scroll to top