Small bowel transplantation complicated by cytomegalovirus tissue invasive disease without viremia.
We report on a small bowel transplant patient, donor/recipient seropositive (D+/R+) for cytomegalovirus (CMV), with a clinical course complicated by CMV disease. Anti-CMV prophylaxis was given for 100 days. Immunosuppression consisted of alemtuzumab, tacrolimus, mycophenolate mofetil and prednisolone. Five months posttransplant, CMV tissue invasive disease of the upper gastrointestinal tract was evident without the presence of viremia, tested by quantitative polymerase chain reaction (PCR). Complete viral load suppression was achieved with intravenous ganciclovir, followed by valganciclovir for secondary prophylaxis. Mycophenolate mofetil and prednisolone were discontinued. Shortly thereafter the patient presented with recurrent CMV and candida esophagitis. While on ganciclovir and caspofungin, the patient developed CMV tissue invasive disease of the ileal graft, with persistent absence of viremia. Foscarnet and CMV immunoglobulin were added. Viral load declined to undetectable levels; however, clinical improvement did not occur due to occurrence of graft rejection. Despite infliximab and high dose prednisolone, graft rejection was progressive, requiring surgical explantation of the graft. This case highlights the importance of additional diagnostic tools such as endoscopy including PCR analysis of tissue samples. Extension of primary antiviral prophylaxis interval up to 6 months and prolonged retreatment for recurrent CMV disease may be useful to avoid severe CMV-related complications.
Department of Transplant Medicine, University Hospital Münster, Münster, Germany.
Yesim
Y
Avsar
Department of Transplant Medicine, University Hospital Münster, Münster, Germany.
Vito R
VR
Cicinnati
Department of Transplant Medicine, University Hospital Münster, Münster, Germany.
Iyad
I
Kabar
Department of General and Visceral Surgery, University Hospital Münster, Münster, Germany.
Heiner
H
Wolters
Department of General and Visceral Surgery, University Hospital Münster, Münster, Germany.
Christoph
C
Anthoni
Department of Transplant Medicine, University Hospital Münster, Münster, Germany.
Hartmut H J
HH
Schmidt
Department of Transplant Medicine, University Hospital Münster, Münster, Germany. Electronic address: susanne.beckebaum@ukmuenster.de.
Susanne
S
Beckebaum
D061605:Administration, Intravenous; D000998:Antiviral Agents / Q000627:therapeutic use; D003587:Cytomegalovirus / Q000302:isolation & purification*; D003586:Cytomegalovirus Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000601:surgery / Q000821:virology; D005260:Female; D015774:Ganciclovir / Q000031:analogs & derivatives / Q000627:therapeutic use; D006801:Humans; D016867:Immunocompromised Host; D007410:Intestinal Diseases / Q000175:diagnosis* / Q000188:drug therapy / Q000601:surgery / Q000821:virology; D007421:Intestine, Small / Q000601:surgery* / Q000821:virology*; D008875:Middle Aged; D016377:Organ Transplantation / Q000009:adverse effects*; D060888:Real-Time Polymerase Chain Reaction; D066027:Transplant Recipients; D000077562:Valganciclovir; D019562:Viral Load; D014766:Viremia
D000998:Antiviral Agents; D000077562:Valganciclovir; D015774:Ganciclovir
Cytomegalovirus; Ganciclovir; Small bowel; Transplantation; Valganciclovir