title: Leflunomide as part of the treatment for multidrug-resistant cytomegalovirus disease after lung transplantation: case report and review of the literature.
abstract: Treatment of cytomegalovirus (CMV) disease in transplant patients is challenging and, with antiviral resistance to first-line drugs, it remains uncertain which treatment algorithm to follow. Some data suggest that leflunomide, a pyrimidine synthesis inhibitor, can be used to treat resistant CMV infections. We report a 57-year-old CMV immunoglobulin-G (IgG)-seronegative woman, who received a bilateral lung transplant (LuTx) from a CMV IgG-positive donor with CMV primary disease. The CMV strain was genotypically resistant to ganciclovir, foscarnet, and cidofovir. After starting leflunomide as add-on therapy to a multidrug anti-CMV regimen, viral load declined substantially in 2 months without adverse events. This experience is discussed against the background of existing literature on the use of leflunomide as an anti-CMV agent in LuTx recipients.
authors.affiliation: Department of Virology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: N J
authors.initials: NJ
authors.lastname: Verkaik
authors.forename: R A S
authors.initials: RA
authors.lastname: Hoek
authors.forename: H
authors.initials: H
authors.lastname: van Bergeijk
authors.forename: P Th W
authors.initials: PT
authors.lastname: van Hal
authors.forename: M E I
authors.initials: ME
authors.lastname: Schipper
authors.forename: S D
authors.initials: SD
authors.lastname: Pas
authors.forename: M F C
authors.initials: MF
authors.lastname: Beersma
authors.forename: C A B
authors.initials: CA
authors.lastname: Boucher
authors.forename: I
authors.initials: I
authors.lastname: Jedema
authors.forename: F
authors.initials: F
authors.lastname: Falkenburg
authors.forename: H C
authors.initials: HC
authors.lastname: Hoogsteden
authors.forename: B
authors.initials: B
authors.lastname: van den Blink
authors.forename: J L
authors.initials: JL
authors.lastname: Murk
mesh_terms: D000998:Antiviral Agents / Q000627:therapeutic use*; D003587:Cytomegalovirus / Q000187:drug effects; D003586:Cytomegalovirus Infections / Q000188:drug therapy* / Q000635:transmission; D024882:Drug Resistance, Viral; D004359:Drug Therapy, Combination; D005260:Female; D017245:Foscarnet / Q000627:therapeutic use; D015774:Ganciclovir / Q000627:therapeutic use; D006801:Humans; D007136:Immunoglobulins / Q000627:therapeutic use; D007555:Isoxazoles / Q000627:therapeutic use*; D000077339:Leflunomide; D016040:Lung Transplantation / Q000009:adverse effects*; D008875:Middle Aged; D019562:Viral Load
chemical_list: D000998:Antiviral Agents; D007136:Immunoglobulins; D007555:Isoxazoles; D017245:Foscarnet; D000077339:Leflunomide; D015774:Ganciclovir
keywords: CMV; cytomegalovirus; foscarnet; ganciclovir; leflunomide; lung transplant; multidrug resistant