Late Cytomegalovirus Infection With Multiple Colonic Perforations in Renal Transplant Recipient – Case Report.

Abstract

Cytomegalovirus (CMV) infection after renal transplantation is major cause of morbidity and mortality. Cytomegalovirus disease typically occurs in fi rst 6 months after transplantation and causes fever, leukopenia, thrombocytopenia and slightly elevated transaminases. More invasive forms of CMV infections are rare because of prophylactic regimen in high-risk patients and early treatment with gancyclovir. We report the case of 36-year-old patient who developed CMV related colonic multiple perforations 3 years after renal transplantation. Initially after transplantation the immunosupressive regimen consisted of steroids(Metypred),calcineurin inhibitor(Prograf)and mycophenolate mofetil(CellCept). CMV infection was not present. Three weeks and 3 months after transplantation the patient presented two incidents of acute rejection treated successfully with antithymotic globulin(fi rst episode) and steroids(second episode). Furthermore in the fi rst year after transplantation patient demonstrated recurrent urinal tract infections and severe Pneumocystis carinii infection treated with Pentamidine. At the same time Prograf was withdrawal. Three years after transplantation patient presented symptoms of enterocolitis(abdomen pain, diarrhea, nausea, weight loss) with biochemical disorders hypoproteinemia, hypoalbuminemia and temporary graft dysfunction. At the beginning of enterocolitis manifestation, investigation of CMV pp65 antigenemia test and CMV-DNA polymerase chain reaction (CMV-DNA PCR) were negative. However CMV IgG antibodies were positive. At that time conversion from CellCept to Myfortic was performed with temporary improvement of symptoms. Six months after fi rst symptoms, colonic biopsy was performed -the histological investigation gave evidence of typical CMV infection. CMV infection was also confi rmed by positive CMV pp65 antigenemia test and CMV-DNA PCR. Ganciclovir therapy was initiated immediately and resulted in improvement of symtoms. However periodically abdomen pain and diarrhea was observed. Control examination of CMV pp65 antigenemia test and CMV-DNA PCR were negative. Three months after ganciclovir therapy symptoms of colonic perforation occured and total colectomy was necessary. The relationship between CMV infection and colonic perforation has been confi rmed by histological examination of the resected colon. Colonic perforationas are often fatal and life-threatening complications in transplant recipients with CMV infection. In such cases only rapid diagnosis and agressive surgical treatment can save the patient from death. The history of our patient illustrated the need to consider CMV infection in patients with enterocolitis symptoms even more than 3 years after solid organ transplantation.