Cytomegalovirus-induced intrahepatic cholestasis complicated by hemophagocytic syndrome in an immunocompetent adult.

Reactivation of cytomegalovirus (CMV) remains a significant concern in patients receiving immunosuppressive therapy. Although CMV infection and reactivation is associated with intrahepatic cholestasis in infants and immunosuppressive adults, intrahepatic cholestasis caused by CMV infection is rare in immunocompetent adults. Here, we report a case with CMV-induced intrahepatic cholestasis in an immunocompetent adult complicated by hemophagocytic syndrome (HPS). We excluded CMV infection from differential diagnosis of intrahepatic cholestasis based on serum CMV antibody profiles and immunocompetency at the initial assessment and then started oral administration of prednisolone (PSL). The development of CMV-induced lethal HPS after the treatment with PSL led us to reconsider the possibility of CMV infection as an etiology of cholestasis. Frozen serum before PSL administration exhibited a high copy number of CMV DNA and thus we reached the final diagnosis of CMV-induced intrahepatic cholestasis complicated by HPS. Resolution of cholestasis and HPS was achieved by ganciclovir. The patient exhibited elevated serum levels of IL-18, C-C motif chemokine ligand 2, and IL-13 with no alterations in serum levels of IFN-γ or TNF-α. This case underscores the importance of consideration of CMV reactivation as a differential diagnosis for intrahepatic cholestasis even in immunocompetent patients.