Objective
To describe a case of with cytomegalovirus (CMV) infection manifesting as pneumonitis.

Case
A boy of three months old came with severe respiratory distress. He was born with normal gestational age, but small for gestational age without any history of resuscitation with caesarean section (CS) due to depleted amniotic fluid. His mother did not perform a TORCH examination during pregnancy. Similar respiratory distress occurred at the first week of age which required mechanical ventilation. In our centre, he was assisted with simple mask oxygen supplementation. Physical findings showed severely stunted infant and crackles in both lungs. No microcephaly, hepatosplenomegaly or chorioretinitis were found. There was no leucocytosis. Chest x-ray showed diffuse infiltrate. He was diagnosed with health care associated pneumonia and were given ampicillin-sulbactam. After seven days of antibiotic administration, the respiratory distress persisted and we found procalcitonin increment. We changed the antibiotic to ceftazidime combined with gentamycin. After changing antibiotic, there was no significant improvement in clinical and radiographic findings. Blood results showed no leucocytosis and sterile blood culture. We reviewed TORCH and immunological examination and found increased serology IgM for CMV. A blood polymerase chain reaction (PCR) yielded positive for CMV. We administered intravenous ganciclovir 5 mg/kgBW/12 hours for 14 days, and his condition improved significantly. After 14 days, the ganciclovir was switched to oral valganciclovir 35 mg/kgBW/12 hours for six weeks. 

Conclusion
Congenital CMV infection can cause neonatal pneumonitis and frequently was not assessed in patients with recurrent episode of pneumonia. The case reported findings of CMV in a small for or gestational age infant which caused pneumonitis. Treatment of CMV infection improved the respiratory symptoms.