Anasarca secondary to cytomegalovirus viremia in a post-liver transplant patient

Introduction: Cytomegalovirus (CMV) infection is a common complication following solid organ transplantation and is associated with significant morbidity. While CMV classically presents with systemic symptoms, bone marrow suppression or gastrointestinal disease, atypical manifestations may occur. Anasarca and refractory ascites in liver transplant recipients are more commonly attributed to graft dysfunction, vascular complications, cardiac disease or renal pathology, and CMV is not often considered as a primary aetiology. Case description: A 63-year-old woman with a history of alcohol-related cirrhosis underwent deceased donor liver transplantation and later presented with progressive abdominal distension and bilateral lower extremity oedema. Evaluation demonstrated tense ascites and anasarca without evidence of graft dysfunction, acute rejection, portal vascular complications, cardiac disease or nephrotic syndrome. Liver function tests were normal, transthoracic echocardiography revealed preserved systolic function, and urinalysis was negative for proteinuria. Further workup identified CMV viremia, and the patient was treated with valganciclovir per infectious disease recommendations, along with supportive measures including diuresis and large-volume paracentesis. Serial monitoring demonstrated improvement in CMV viral load with corresponding gradual resolution of fluid retention. Conclusion: This case highlights CMV viremia as an important and potentially reversible cause of anasarca in post-liver transplant patients, likely mediated by CMV-induced endothelial dysfunction. Recognition of CMV-related fluid retention is essential to avoid unnecessary invasive procedures and to guide timely antiviral therapy in immunosuppressed individuals. LEARNING POINTS: Cytomegalovirus (CMV) infection should be considered in the differential diagnosis of unexplained anasarca and refractory ascites in liver transplant recipients, even in the absence of graft dysfunction or classic CMV symptoms.A systematic evaluation to exclude cardiac, renal, vascular and graft-related causes of fluid overload is essential before attributing post-transplant anasarca to non-infectious aetiologies.Early recognition and treatment of CMV viremia can lead to clinical improvement and optimise outcomes in immunosuppressed patients.