Cytomegalovirus Reactivation and its Viral Load Kinetics in Tracheal Aspirate of Moderate-to-severe ARDS Patients

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INTRODUCTION: Evidence indicates that cytomegalovirus (CMV) reactivation can occur in individuals who are not overtly immunosuppressed during periods of acute illness, and such reactivation has been linked to poorer clinical outcomes.(1–3) Patients with acute respiratory distress syndrome (ARDS) often have a long and complicated disease course in the ICU, which portends a particular risk for viral reactivations.(4,5) OBJECTIVES: To study the prevalence of CMV reactivation and its viral load kinetics in the tracheal aspirate of moderate to severe ARDS patients. MATERIALS AND METHODS: After ethics committee approval, this prospective study screened all consecutive adult ICU patients with moderate to severe ARDS for the presence of CMV seropositivity (anti-CMV IgG antibodies). Exclusion criteria were: age < 18 years, use of antiviral agents within the preceding 7 days, known or suspected underlying immune deficiencies, and pregnant patients. Tracheal samples from the included patients were analysed for CMV reactivation weekly for up to 4 weeks after meeting the criteria for moderate to severe ARDS (P/F ratio ≤200). Further, in cases of CMV reactivation, 3 more samples (maximum) were collected weekly to assess the viral load kinetics. Real-time PCR was performed on tracheal aspirate samples, and CMV DNA load was expressed as copies/mL. CMV reactivation was defined as viral load >1000 copies/ml. RESULTS: During the study period (Jul 2024- Oct 2025), 27 out of 50 patients met the eligibility criteria. At the time of ICU admission, the median age was 39 years (IQR 26-58), and 62.06% were male. At study inclusion, the median SOFA score was 10 (IQR 8-13.5). A total of 114 samples were analysed. CMV reactivation was observed in 13 out of 27 patients (48.14%). The clinical characteristics of patients with CMV reactivation compared to those without reactivation were as follows: age 42 versus 32 years; SOFA score at inclusion 11 versus 9.5 (p = 0.286); length of stay 40 (IQR 20-47) versus 35 (IQR 24-45) days (p = 0.29). Bacterial growth in tracheal culture 10 versus 11. The mortality rate at 28 days after inclusion was 69.23% (9/13) in the CMV reactivation group, compared with 42.85% (6/14) in the non-reactivation group (p ≤ 0.01). At the time of reactivation (figure 1), the median copies (per ml) among non-survivors in tracheal samples were 32,000 (IQR 19,500-1,43,000) as compared to 32,425 (IQR 20,575-81,887) in survivors, which increased to 2,40,000 (IQR 1,79,450-2,75,000) versus 59,500(IQR 36,000-1,33,750) in follow-up samples, respectively. SUMMARY: This Prospective study (Jul 2024- Oct 2025) was done on 27 adult ICU patients to look for CMV reactivation and its viral load kinetics in moderate to severe ARDS. It showed CMV reactivation occurred in 48.14%, with significantly higher mortality in comparison to patients without reactivation. CONCLUSIONS: CMV reactivation occurred in 48.14% of patients with moderate to severe ARDS, with significantly higher mortality in comparison to patients without reactivation. Among CMV reactivation, non-survivors have higher median CMV copies, which continued to rise in follow-up weeks.

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