title: Unusual case of severe late-onset cytomegalovirus-induced hemorrhagic cystitis and ureteritis in a renal transplant patient.
abstract: Cytomegalovirus (CMV) infection is common in solid organ transplant recipients and accounts for the majority of graft compromise. Major risk factors include primary exposure to CMV infection at the time of transplantation and the use of antilymphocyte agents such as OKT3 (the monoclonal antibody muromonab-CD3) and antithymocyte globulin. It most often develops during the first 6 months after transplantation. Although current prophylactic strategies and antiviral agents have led to decreased occurrence of CMV disease in early posttransplant period, the incidence of late-onset CMV disease ranges from 2% to 7% even in the patients receiving prophylaxis with oral ganciclovir. The most common presentation of CMV disease in transplant patients is CMV pneumonitis followed by gastrointestinal disease. Hemorrhagic cystitis is a common complication following hematopoietic stem cell transplantation. The condition is usually due to cyclophosphamide-based myeloablative regimens and infectious agents. Even in these settings, CMV-induced cases occur only sporadically. Ureteritis and hemorrhagic cystitis due to CMV infection after kidney transplantation is reported very rarely on a case basis in the literature so far. We report here a case of late-onset CMV-induced hemorrhagic cystitis and ureteritis presenting with painful macroscopic hematuria and ureteral obstruction after 4 years of renal transplantation. The diagnosis is pathologically confirmed by the demonstration of immunohistochemical staining specific for CMV in a resected ureteral section. We draw attention to this very particular presentation of CMV hemorrhagic cystitis with ureteral obstruction in order to emphasize atypical presentation of tissue-invasive CMV disease far beyond the timetable for posttransplant CMV infection.
authors.affiliation: Division of Nephrology, Department of Internal Medicine, Dokuz Eylul University Hospital, Izmir, Turkey. sibel.ersan@deu.edu.tr
authors.forename: Sibel
authors.initials: S
authors.lastname: Ersan
authors.forename: Kutsal
authors.initials: K
authors.lastname: Yorukoglu
authors.forename: Mehmet
authors.initials: M
authors.lastname: Sert
authors.forename: Koray
authors.initials: K
authors.lastname: Atila
authors.forename: Ali
authors.initials: A
authors.lastname: Celik
authors.forename: Aytac
authors.initials: A
authors.lastname: Gulcu
authors.forename: Caner
authors.initials: C
authors.lastname: Cavdar
authors.forename: Aykut
authors.initials: A
authors.lastname: Sifil
authors.forename: Seymen
authors.initials: S
authors.lastname: Bora
authors.forename: Hüseyin
authors.initials: H
authors.lastname: Gulay
authors.forename: Taner
authors.initials: T
authors.lastname: Camsari
mesh_terms: D003556:Cystitis / Q000821:virology*; D003586:Cytomegalovirus Infections / Q000150:complications*; D006470:Hemorrhage / Q000821:virology*; D006801:Humans; D007249:Inflammation / Q000821:virology*; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000821:virology*; D012720:Severity of Illness Index; D013997:Time Factors; D014515:Ureteral Diseases / Q000821:virology*