title: Severe cytomegalovirus infection in a second kidney transplant recipient treated with ganciclovir, leflunomide, and immunoglobulins, with complications including seizures, acute HCV infection, drug-induced pancytopenia, diabetes, cholangitis, and multi-organ failure with fatal outcome: a case report.
abstract: BACKGROUND
  Cytomegaly remains one of the most common infectious complications in organ transplant recipients, and the course of the infection may have a negative effect on survival of the transplant and recipient.
  
  
  METHODS
  We describe the case of a 32-year-old female patient who received a second kidney transplant from a cadaveric donor in July 2012, treated successfully with ganciclovir for primary CMV infection in August 2012 and then re-treated from November due to re-infection. The viral load at the start of re-treatment was 6 million copies. In view of ganciclovir treatment failure, Sando immunoglobulins were administered. Subsequently, when CMV viral load increased to 18 million copies, a decision was made to use combination treatment with leflunomide and ganciclovir. Immunosuppressive treatment was also modified by administering everolimus in view of its potential antiviral activity. Seizures, pancytopenia, diabetes, diarrhoea, and (probably) drug-induced liver damage and cholangitis were observed in the course of treatment. At 3 months of hospitalization, the patient was discharged home with viral load of 8000 copies. As treatment continuation, she received valganciclovir at the full therapeutic dose in view of very good kidney function (creatinine 0.7 mg/dl). The patient was re-hospitalized after 10 days due to fever and cough. Due to abnormal liver function test results and negative serum markers of viral hepatitis, HCV RNA was tested, with a positive result (above 10^8 copies). Subsequently, decline in clinical status, overhydration, increasing creatinine levels, hepatic failure signs, and renewed CMV DNA increase to 520 000 copies were observed. Despite intensive treatment, the patient died of multi-organ failure.
  
  
  CONCLUSIONS
  The case described illustrates the difficulties in the treatment of CMV infection and its possible dramatic complications.
authors: Department of Transplantation Medicine and Nephrology, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland.
authors: Dorota
authors: D
authors: Miszewska-Szyszkowska
authors: Department of Transplantation Medicine and Nephrology, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland.
authors: Natalia
authors: N
authors: Mikołajczyk
authors: Department of Transplantation Medicine and Nephrology, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland.
authors: Ewa
authors: E
authors: Komuda-Leszek
authors: Department of Transplantation Medicine and Nephrology, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland.
authors: Renata
authors: R
authors: Wieczorek-Godlewska
authors: Department of Transplantation Medicine and Nephrology, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland.
authors: Robert
authors: R
authors: Świder
authors: Department of Transplantation Medicine and Nephrology, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland.
authors: Dominika
authors: D
authors: Dęborska-Materkowska
authors: Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland.
authors: Jacek
authors: J
authors: Szmidt
authors: Department of Transplantation Medicine and Nephrology, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland.
authors: Magdalena
authors: M
authors: Durlik
mesh_terms: D000328:Adult; D000998:Antiviral Agents / Q000627:therapeutic use; D002761:Cholangitis / Q000150:complications*; D003586:Cytomegalovirus Infections / Q000150:complications* / Q000188:drug therapy; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D017809:Fatal Outcome; D005260:Female; D015774:Ganciclovir / Q000627:therapeutic use; D006526:Hepatitis C / Q000150:complications*; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007555:Isoxazoles / Q000627:therapeutic use; D016030:Kidney Transplantation / Q000009:adverse effects*; D000077339:Leflunomide; D009102:Multiple Organ Failure / Q000150:complications*; D010198:Pancytopenia / Q000139:chemically induced / Q000150:complications*; D012086:Reoperation; D012640:Seizures / Q000150:complications*; D066027:Transplant Recipients; D019562:Viral Load
chemical_list: D000998:Antiviral Agents; D016756:Immunoglobulins, Intravenous; D007555:Isoxazoles; D000077339:Leflunomide; D015774:Ganciclovir