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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 263-265

A case report of late-onset gastrointestinal cytomegalovirus infection 17 years post kidney transplantation


1 Department of Nephrology, Madras Medical Mission, Chennai, Tamil Nadu, India
2 Department of Pathology, Madras Medical Mission, Chennai, Tamil Nadu, India
3 Department of Gastroenterology, Madras Medical Mission, Chennai, Tamil Nadu, India

Date of Submission20-Feb-2020
Date of Acceptance05-Aug-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Georgi Abraham
Department of Nephrology, Madras Medical Mission, Chennai - 600 037, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_15_20

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  Abstract 


Cytomegalovirus (CMV) infection, one of the most common viral infections seen post-transplantation, is rarely known to occur after 15 years. Here, we report a 59-year-old male on minimum immunosuppressive agents who presented with abdominal pain and was found to have CMV infection of the distal ileum with concurrent high CMV viral load 17 years post kidney transplantation.

Keywords: Cytomegalovirus, kidney transplantation, opportunistic infections


How to cite this article:
Anupama SH, Koshy P, Saraswathy AR, Parthasarathy R, Mathew M, Abraham G. A case report of late-onset gastrointestinal cytomegalovirus infection 17 years post kidney transplantation. Indian J Transplant 2020;14:263-5

How to cite this URL:
Anupama SH, Koshy P, Saraswathy AR, Parthasarathy R, Mathew M, Abraham G. A case report of late-onset gastrointestinal cytomegalovirus infection 17 years post kidney transplantation. Indian J Transplant [serial online] 2020 [cited 2020 Oct 20];14:263-5. Available from: https://www.ijtonline.in/text.asp?2020/14/3/263/296881




  Introduction Top


Cytomegalovirus (CMV) disease is one of the key infectious causes of morbidity and mortality seen post kidney transplant worldwide.[1] Infection with CMV is seen commonly after kidney transplantation and can be classified as primoinfection or reactivation.[2] In solid-organ transplant receivers, treatment of CMV infection decreases the risk of allograft damage and thereby the fatality.[3],[4] The incidence of CMV infection during the first 100 days posttransplant is 60% without preemptive measures, while it is drastically reduced to 25% in patients on prophylactic therapy.[5] A diagnosis of CMV infection is established after detection of CMV proteins or nucleic acid or isolation of CMV or in a clinical specimen. The incidence of CMV infection ranges from <5% when both donor and recipients are found to be negative against CMV antibodies to as high as 50%–75% when the donor tests positive and the recipient is negative (D+/R−). Regardless of the CMV antibody level of the donor, when recipient antibody status is affirmative, the incidence for CMV infection is 25%–40%.[6] Late-onset CMV infection is rather rare. CMV status of donor being positive and recipient being negative and allograft rejection present as potential risk factors for late-onset CMV disease.[7]


  Case Report Top


A 54-year-old kidney transplant male patient on minimal immunosuppression presented to the outpatient department 17 years post-transplant with a history of diffuse abdominal pain, on and off, for one month. He had no other associated symptoms. On probing further, the patient revealed a history of weight loss of 1 kg.

On admission, hemoglobin was 10.5 mg/dl, white blood cell was 6400, and creatinine was 1.2 mg. Urine analysis was unremarkable. Total protein/albumin was 5.8/3 g/dl. Serum amylase was 56 IU/l. Serum glutamic pyruvic transaminase was 9 mg, and serum glutamic oxaloacetic transaminase was 13 mg. Other laboratory parameters were within normal limits. Currently, anti-HIV and hepatitis C virus were negative. Magnetic resonance imaging whole abdomen revealed a long-segment, diffuse circumferential wall thickening of the distal ileum [Figure 1]. Colonoscopy showed distal ileal ulcers suggestive of tuberculosis, inflammatory bowel disease, lymphoma, or colonic diverticulosis following which a segmental biopsy was taken [Figure 2], which showed CMV inclusion bodies with ulceration and mixed inflammatory exudates [Figure 3]. Immunohistochemistry was done, showing anti-CMV antibodies [Figure 4]. Real-time polymerase chain reaction (RT-PCR) of peripheral blood showed CMV viral load of 2,604,787 copies/ml. The patient was treated for miliary tuberculosis for over a year in 2011. On gene Xpert of ileal tissue biopsy for Mycobacterium tuberculosis (MTB)/rifampicin assay (RT-PCR), MTB was not detected. Ileal tissue culture showed growth of  Escherichia More Details coli. Subsequently, the patient was started on tablet valacyclovir 900 mg per oral twice daily, which was well tolerated. The patient continues follow-up on an outpatient basis with good graft function.
Figure 1: Magnetic resonance imaging whole abdomen revealed long-segment, diffuse circumferential wall thickening of the distal ileum

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Figure 2: Colonoscopy showing distal ileal ulcers

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Figure 3: (a) Intranuclear inclusion bodies. (b) Intracytoplasmic inclusion bodies

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Figure 4: Immunohistochemistry showing anti-Cytomegalovirus antibodies

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  Discussion and Conclusion Top


CMV infection, the most common infection seen after transplantation, has acquired various diagnostic modalities over the year. Two major methods used to diagnose active CMV infection are the pp65 antigenemia assay and PCR, which takes 7 and 11 days (median) to show positivity in the presence of CMV. Other methods include serology, immunohistochemistry, nucleic acid sequence-based amplification, hybrid capture assay, and cell culture. Despite being considered to be the best modality of diagnosis, the antigenemia test is subjective to the skill of the person performing it. It also requires the blood sample to be tested within six hours of collection, which may not be possible at all times. PCR method is used more commonly since it overcomes these drawbacks and is rapid in diagnosis.[8]

The treatment of CMV infection is recommended with intravenous ganciclovir for 14–28 days. Patients unsuitable to treatment with ganciclovir or patients unwilling to injectables can be treated alternatively with valacyclovir. Asymptomatic patients can be treated with valganciclovir. If the diagnosis of viremia is made with antigenemia, maintenance of treatment for one week after obtaining the negative result is recommended, since PCR persists as positive during this period. Patients with invasive disease should be treated for 21–28 days. Risk reduction is possible by preemptive prophylaxis and prompt treatment.

According to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines, all donor candidates must be initially screened for anti-CMV IgG Ab.[2] Positivity does not forestall transplantation, and the recipient is started on post-transplant antiviral prophylaxis. KDIGO recommends chemoprophylaxis for CMV infection in kidney transplant recipients (except for D-/R-) with oral ganciclovir or valganciclovir for three months after transplantation and post-treatment with a T-cell depleting antibody for six weeks.[9]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Anand S, Yabu JM, Melcher ML, Kambham N, Laszik Z, Tan JC. Cytomegalovirus in the transplanted kidney: A report of two cases and review of prophylaxis. NDT Plus 2011;4:342-5.  Back to cited text no. 1
    
2.
Requião-Moura LR, deMatos AC, Pacheco-Silva A. Cytomegalovirus infection in renal transplantation: Clinical aspects, management and the perspectives. Einstein (Sao Paulo) 2015;13:142-8.  Back to cited text no. 2
    
3.
Dunn DL, Mayoral JL, Gillingham KJ, Loeffler CM, Brayman KL, Kramer MA, et al. Treatment of invasive cytomegalovirus disease in solid organ transplant patients with ganciclovir. Transplantation 1991;51:98-106.  Back to cited text no. 3
    
4.
Keay S, Petersen E, Icenogle T, Zeluff BJ, Samo T, Busch D, et al. Ganciclovir treatment of serious cytomegalovirus infection in heart and heart-lung transplant recipients. Rev Infect Dis 1988;10 Suppl 3:S563-72.  Back to cited text no. 4
    
5.
Sagedal S, Nordal KP, Hartmann A, Degré M, Holter E, Foss A, et al. A prospective study of the natural course of cytomegalovirus infection and disease in renal allograft recipients. Transplantation 2000;70:1166-74.  Back to cited text no. 5
    
6.
Sagedal S, Hartmann A, Rollag H. The impact of early cytomegalovirus infection and disease in renal transplant recipients. Clin Microbiol Infect 2005;11:518-30.  Back to cited text no. 6
    
7.
Cope AV, Sabin C, Burroughs A, Rolles K, Griffiths PD, Emery VC. Interrelationships among quantity of human cytomegalovirus (HCMV) DNA in blood, donor-recipient serostatus, and administration of methylprednisolone as risk factors for HCMV disease following liver transplantation. J Infect Dis 1997;176:1484-90.  Back to cited text no. 7
    
8.
Azevedo LS, Pierrotti LC, Abdala E, Costa SF, Strabelli TM, Campos SV, et al. Cytomegalovirus infection in transplant recipients. Clinics (Sao Paulo) 2015;70:515-23.  Back to cited text no. 8
    
9.
Boudville N, Kanellis J. KHA-CARI commentary on the KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Nephrology (Carlton) 2020;25:96-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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