To describe a rare case of simultaneous CMV infection and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), presenting with mononeuritis multiplex and ventral nerve root enhancement, prior to the initiation of immunosuppressive therapy.

Case study

A 72-year-old woman with hypertension presented with one month of rapidly progressive weakness and inability to ambulate. On exam, she had significant distal weakness of her extremities with left hand “benediction sign” median neuropathy, bilateral foot drop and length dependent sensory loss. EMG/NCS was consistent with mononeuritis multiplex. MRI T-spine showed ventral nerve root enhancement. CSF analysis was normal. Additionally, she had purpuric lesions in her palms and soles, proteinuria, and pulmonary nodules. Her hospital course was complicated by an acute GI bleed. Endoscopy showed esophageal and gastric ulcers which were CMV positive and treated with ganciclovir. Rheumatologic workup yielded elevated serum RF (215 IU/ml), ANA (1:80), and Proteinase-3 antibody (35.5 IU/mL) consistent with AAV. She was treated with IV methyprednisolone and rituximab followed by oral steroid taper.  After treatment, patient had improvement of weakness and could ambulate with assistance.