cytomegalovirus ( cmv ) infections have a worldwide impact due to the high congenital infection rates , disease burden and associated costs .
it has a seroprevalence of 30100% depending on the age , ethnicity as well as social and immune status of the study group [ 1 , 2 , 3 ] .
transmission occurs via secretions like tears , saliva , urine , genital secretions , breast milk or blood .
afterwards , the virus may remain clinically silent or appear with unspecific symptoms like fatigue , cough or fever in immunocompetent patients .
by contrast , infections may result in severe disease and failure of several organs in patients with a congenital or acquired immunodeficiency , e.g. due to hiv , the infantile immune system of newborns or under immunosuppressive therapy .
the drugs of choice for treatment of cmv infections in immunosuppressed hosts are ganciclovir and valganciclovir for a less severe disease .
upper right abdominal pain is one of the major symptoms when the liver is affected and is associated with elevated liver enzymes .
the severity may vary from mild elevated enzymes to acute liver failure . in this case report , we present the case of a female patient with upper right abdominal pain and gallstones . after a cholecystectomy she had no pain relief , leading to an extensive investigation cascade resulting in this rare diagnosis .
a 35-year - old obese female patient of eritrean origin presented as an outpatient with epigastralgia and vomiting for 2 months .
one week later she presented to the emergency department with ongoing pain in the upper right abdomen .
the postoperative ultrasound was normal , and we found slightly elevated liver enzymes with alanine transaminase ( alt ) 101 u / l , aspartate transaminase ( ast ) 123 u / l and gamma - glutamyl transpeptidase ( ggt ) 128 u / l .
she was prescribed pain medication and was scheduled for a follow - up visit the next day .
the laboratory test of the next day showed a strong increase of the liver enzymes with alt 1,521 u / l , ast 1,336 u / l and ggt 618 u / l ( fig .
she complained of undiminished pain in spite of pain medication . in order to look for an abscess or an acute ischemia of the liver , the patient was hospitalized and a computed tomography ( ct ) of the abdomen was performed . after inconspicuous results of the ct
, a magnetic resonance cholangiopancreatography was performed addressing the question of pathology of the biliary duct system .
it did not show any pathological result . with the working diagnosis of a cholangitis with increasing liver enzymes , infectious parameters with c - reactive protein ( crp ) 267 mg / l and leucocytes ( lc ) 15  10/l at their maximum and impaired coagulation with a spontaneous international normalized ratio of 1.2 ( fig . 1 , fig
3 ) , antibiotic therapy with amoxicillin / clavulanic acid was initiated . in absence of a clinical improvement and a further increase of the liver enzymes ,
a hepatitis serology was performed and showed seropositivity for a former hepatitis type a. the simultaneously performed screening for ebv , hiv and cmv showed a former infection of ebv and an acute infection of cmv .
an antiviral medication was omitted due to its toxicity , and antibiotic therapy was terminated . with clinical and laboratory recovery (
crp 51 mg / l ; lc 8.1  10/l ; ast 29 u / l ) , the patient could be discharged on day 9 of the second in - patient stay .
in this immunocompetent patient , we diagnosed an acute cmv infection with hepatitis by immunoassay testing . following the guidelines , we did not install an antiviral therapy , which was not indicated in our case . in a patient presenting with highly elevated liver enzymes and parameters of cholestasis but without elevated bilirubin , one must think of hepatitis .
any patient with the appropriate risk profile should be tested for hepatitis a , b and c. if these serological tests do not confirm acute hepatitis , further serological profiles including hiv , ebv and cmv should be included .
retrospectively , the upper abdominal pain in our patient may have been based on the acute cmv infection and not due to the gallstones shown in the radiologic diagnostics .
but at that time , the liver enzymes were not elevated , and symptomatic gallstones are very common and serological testing is time - consuming and expensive .
therefore , the cholecystectomy is still indicated , although in this case , the surgery may have aggravated the cmv infection .
postoperatively , surgical complications must be ruled out because they are more common in this setting .
it is also presumed to be a major cause of mortality in immunocompromised patients . the gold standard to confirm the diagnosis is the presence of cmv - specific antibodies type igg and igm in the ( maternal ) blood sample running an immunoassay or a polymerase chain reaction , which can be either qualitative or quantitative by measuring the amount of viral dna in the respective sample[4 , 5 ] .
cmv disease typically presents as mild and self - limiting mononucleosis syndrome without an organ complication .
cmv diseases are more often complicated in hiv - positive or other immunocompromised patients like those with organ transplantation , bone marrow transplantation , neutropenia due to chemotherapy or radiation therapy .
other manifestations include peripheral neuropathy , polyradiculoneuritis , pneumonitis , gastritis , colitis , and hepatitis .
hepatitis as a manifestation of cmv infection is a rare but known complication usually not needing antiviral therapy due to its self - limiting course .
antiviral treatment is reserved for severe cmv infections because of its potential side effects including myelosuppression , central nervous system disorders , hepatotoxicity , irreversible infertility ( inhibition of spermatogenesis ) , or teratogenesis .
indications for antiviral treatment are mostly based on the clinical course and on the polymerase chain reaction threshold .
the cutoff varies from institution to institution but in general it is located around 10,000 viral copies / ml of blood .
when treatment is needed , it should be given for a minimum of 23 weeks .
the end point of intravenous therapy is the documented clearance of virus from the blood .
regimens for adults should be adjusted for renal dysfunction ( table 1 ) . to avoid a relapse after intravenous therapy , oral treatment with valganciclovir for 23 months
may be performed in high - risk patients ( table 2 ) [ 8 , 9 ] .
with this case report , we want to raise the awareness for an unusual diagnosis : an acute cmv infection .
if common reasons for upper right abdominal pain are ruled out , clinical symptoms are persistent , and liver enzymes are elevated , this diagnosis should be sought , regardless whether patients are immunocompetent or not .
written informed consent was obtained from the patient for publication of this case report and the accompanying tables and figures .
 cytomegalovirus infections are widely distributed with a seroprevalence of up to 100% . 
 the majority of the cases take a silent course or deal with unspecific clinical symptoms . 
 complications in immunocompetent patients are rare but may affect the liver and lead up to an acute organ failure . in this case report , we describe a 35-year - old immunocompetent female with an acute cytomegalovirus infection presenting as acute hepatitis with ongoing upper right abdominal pain after cholecystectomy . 
 upper right abdominal pain is a common symptom with a wide range of differential diagnoses . 
 if common reasons can be excluded , we want to sensitize for cytomegalovirus infection as a minor differential diagnosis even in immunocompetent patients . 
Background
Case Presentation
Discussion
Conclusions
Statement of Ethics
Disclosure Statement