Late and Atypical Cytomegalovirus Disease in Solid‐Organ Transplant Recipients

Abstract

Posttransplantation cytomegalovirus (CMV) disease typically occurs 1-4 months after solid-organ transplantation. The case definition invariably includes unexplained fever for > or =3 days, often with leukopenia. Late and atypical presentation of CMV disease has been rarely reported. Five cases of late and atypical CMV disease in heart (n = 1), liver (n = 1), and kidney (n = 3) transplant recipients occurred within a 4-month period in early 1999. These patients presented at a median of 25 months after organ transplantation (range, 6 months to 22 years). Atypical findings included absence of fever in 3 patients, elevated white blood cell counts in 4 patients, and normal platelet counts in 4 patients. Four patients were at risk for primary CMV infection, and 3 received ganciclovir prophylaxis for 3 months. One patients was treated for rejection, and 2 patients had induction muromonab-CD3 (Orthclone; Orthobiotech). Two of the patients had pulmonary CMV disease, but neither of these patients had hypoxia. Two patients had enterocolitis, one of whom had chronic colitis for a year. These cases may represent a changing epidemiology and clinical presentation of CMV disease in solid-organ transplant recipients in an era of changing immunosuppression and improved CMV disease prevention in the early posttransplantation period.

The case for cytomegalovirus prophylaxis in solid organ transplantation

“…We, and others, have also noted that late onset disease may have very atypical features [36][37][38]. Some of the change in epidemiology for CMV disease may be due to the use of prophylaxis, but some may be due to changes in immunosuppression [39] or our ability to recognise such late cases.…”

“…One can acknowledge that the current strategy of CMV prevention with prophylaxis is imperfect at best but the ease of administration and the general overall effectiveness of this approach are well accepted and have been documented over the past decade. Clinicians need to be aware of late onset CMV disease, as well as the atypical manifestations of CMV disease at this time [36,37,39]. Late disease in patient populations that are not in the highest risk serologic strata is extremely rare but can occur.…”

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“…1 The disease may present with nonspecific signs and symptoms such as fever, malaise, body pain, leukopenia, or it may present with signs and symptoms of organs involved such as colon, liver, lung, or retina. 3 Cytomegalovirus peritonitis is considered a rare manifestation of CMV disease.…”

“…1 Posttransplant disease may occur without specific organ involvement, which is referred to as CMV syndrome, and may involve specific organs. The colon is the most commonly affected organ; however, other organs including the liver, the retina, and the lung also may be involved.…”

Ureteritis por citomegalovirus en receptor de trasplante renal: Informe de un caso con presentación inusual

“…Típicamente, la enfermedad por CMV ocurre en los primeros 6 meses pos-trasplante renal, con un pico de máxima incidencia entre el segundo y cuarto mes 1,2,3 , y se caracteriza por la presencia de signos y síntomas sistémicos. Sin embargo hay casos informados de presentaciones atípicas y tardías de la infección por CMV 4 . Existen pocos informes de ureteritis por CMV en receptores de trasplante renal, que suelen presentarse como obstrucción ureteral y/o disfunción del injerto renal y que podrían estar emergiendo como una complicación cada vez más frecuente [5][6][7][8][9][10][11] .…”