Most clinically significant infections are seen in setting of immunosuppression
Etiology/Pathogenesis
• Infection can be acquired before birth, at birth, or later in life
Following active infection, latent infection may persist for years
Clinical Issues
• Clinical (and histologic) presentation of CMV hepatitis depends on age and immune status of patient
Most infections in immunocompetent patients are clinically silent
Immunocompromised patients have highly variable presentation
– Highest risk of infection in transplant patients is seronegative recipient/seropositive donor
Congenital infection ranges from asymptomatic to severe
• Helpful laboratory tests include serologies and PCR from blood
Microscopic
• Characteristic cytoplasmic and nuclear enlargement with intranuclear and intracytoplasmic inclusions
Inclusions can be seen within hepatocytes, biliary epithelium, endothelial cells, and Kupffer cells
Immunocompromised and neonatal patients have variably present portal and lobular inflammation
• Immunocompetent patients can have mononucleosis-like pattern with sinusoidal lymphocytic infiltrate and absence of viral inclusions
Cytomegalovirus Inclusions Both biliary epithelium and hepatocytes contain characteristic CMV inclusions. The nuclear inclusions have a halo around them that confers the characteristic owl’s eye appearance.
Cytomegalovirus Immunohistochemistry CMV immunohistochemistry highlights 2 viral inclusions within endothelial cells in a small capillary.
Microabscess Lobular neutrophilic microabscesses may be a histologic clue to hepatic CMV infection. An inclusion is seen in the center of the microabscess in this liver transplant patient.
Lobular Lymphocytosis Some cases of CMV feature a mononucleosis-like pattern similar to EBV infection in the liver, with a lobular lymphocytic infiltrate within the hepatic sinusoids in a string of beads configuration .
TERMINOLOGY
Abbreviations
• Cytomegalovirus (CMV)
Synonyms
• HHV-5
Definitions
• Member of Herpesviridae family, capable of infecting many cell types
Identified in numerous body fluids (blood, semen, saliva)
• At least 60% of adults in USA have serologic evidence of past infection
Higher rates in developing countries and in HIV(+) patients
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and hepatocytes 
contain characteristic CMV inclusions. The nuclear inclusions have a halo around them that confers the characteristic owl’s eye appearance.
is seen in the center of the microabscess in this liver transplant patient.
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