title: Recurrent cytomegalovirus disease, visceral leishmaniosis, and Legionella pneumonia after liver transplantation: a case report.
abstract: OBJECTIVE
  Recurrent cytomegalovirus (CMV) disease is a frequent complication of liver transplantation. Visceral leishmaniosis in a transplant recipient is, on the other hand, extremely rare and only two cases of kala-azar have been described after liver transplantation. Immunosuppressed patients are known to be at risk of Legionella infection and the relationship between infection with this organism and hospital water supplies has been well described. These three diseases carry a high mortality rate. Our report examines the potential relationship between these complications.
  
  
  METHODS
  We describe the case of a liver transplant recipient who presented the three complications successively and survived. After reviewing the literature, we explore hypotheses linking these infections and discuss treatment strategies.
  
  
  CONCLUSIONS
  In the patient described, infection with leishmania probably occurred months prior to the clinical presentation, a delay that matches the incubation period of kala-azar. The simultaneous onset of leishmaniosis and of a high CMV viremia may have been a coincidence. However, CMV infection has been shown to be an independent predictor of invasive fungal infection in liver transplant recipients. CMV does indeed have a suppressive effect on the humoral and cellular immune response in vitro as well as in vivo. The clinical manifestations of leishmaniosis may, therefore, have been precipitated in this patient by the additive immunosuppressive effect of antirejection drugs and CMV.
authors.affiliation: Department of Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland. nhalkic@hospvd.ch
authors.forename: Nermin
authors.initials: N
authors.lastname: Halkic
authors.forename: Riadh
authors.initials: R
authors.lastname: Ksontini
authors.forename: Beatrix
authors.initials: B
authors.lastname: Scholl
authors.forename: Catherine
authors.initials: C
authors.lastname: Blanc
authors.forename: Tibor
authors.initials: T
authors.lastname: Kovacsovics
authors.forename: Pascal
authors.initials: P
authors.lastname: Meylan
authors.forename: Carmen
authors.initials: C
authors.lastname: Muheim
authors.forename: Michel
authors.initials: M
authors.lastname: Gillet
authors.forename: François
authors.initials: F
authors.lastname: Mosimann
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000967:Antimony Sodium Gluconate / Q000627:therapeutic use; D000998:Antiviral Agents / Q000627:therapeutic use; D001842:Bone and Bones / Q000469:parasitology / Q000473:pathology; D017291:Clarithromycin / Q000627:therapeutic use; D003428:Cross Infection / Q000453:epidemiology / Q000628:therapy; D003586:Cytomegalovirus Infections / Q000150:complications* / Q000188:drug therapy / Q000821:virology; D017245:Foscarnet / Q000627:therapeutic use; D015774:Ganciclovir / Q000627:therapeutic use; D006801:Humans; D007877:Legionnaires' Disease / Q000150:complications* / Q000188:drug therapy / Q000628:therapy; D007898:Leishmaniasis, Visceral / Q000150:complications* / Q000188:drug therapy / Q000469:parasitology; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology* / Q000628:therapy; D012556:Schistosomicides / Q000627:therapeutic use; D019562:Viral Load
chemical_list: D000900:Anti-Bacterial Agents; D000998:Antiviral Agents; D012556:Schistosomicides; D017245:Foscarnet; D017291:Clarithromycin; D015774:Ganciclovir; D000967:Antimony Sodium Gluconate