Predictors of persistent diarrhea in norovirus enteritis after solid organ transplantation

Abstract

Solid organ transplant (SOT) recipients may develop protracted diarrheal illness from norovirus. We performed a retrospective chart review between January 2010 and April 2014 to identify predictors of persistent diarrhea in transplant recipients with norovirus enteritis. A total of 152 SOT recipients with mean age of 31.5 years (SD 23.1) were included: 43.4% male, 34.2% pediatric patients. Allograft types were abdominal 136 (89.5%) (kidney [39.5%], liver-small bowel [23%], other [27%]) and thoracic 16 (10.5%). The median time to diagnosis of first norovirus enteritis episode from date of transplantation was 1.7 (0.3-5.3) years. At time of presentation, diarrhea was present in 141 (93%). Thirty percent had persistent diarrhea at 2 weeks. Hospitalization was required for treatment in 121 (80%) of episodes with the mean length of stay of 10±15.2 days. Most (91%) infections were due to norovirus genogroup II, and gastrointestinal coinfections were seen in 23 (19%) norovirus enteritis episodes. Nausea at time of diagnosis (P=.002) and cytomegalovirus (CMV) infection in the preceding 90 days (P=.036) were identified as independent risk factors for persistent diarrhea using univariate and multivariable logistic regression. Our study shows that nausea on presentation and prior CMV infection were associated with persistent diarrhea in patients with norovirus enteritis.

Clinical presentation and outcomes of norovirus infection in intestinal allograft compared to native intestine

“…Each individual patient was included only once, at the time of the first positive test. The patients included in this study were previously included in a previous analysis with a different focus—looking to identify predictor factors of persistent diarrhea in any transplant recipients with NVE . Variables collected included: age; gender; allograft(s) transplanted; induction therapy; maintenance immunosuppression regimen at the time of positive test; mean tacrolimus level during the month prior to diagnosis of NV infection; rejection episodes; graft loss during the follow‐up period; symptoms at the diagnosis and end of treatment (nausea, vomiting, diarrhea, fever, weight loss); frequency of bowel movements; volume of stool; mortality; laboratory values at presentation and end of therapy (white blood cells [WBCs], creatinine and creatinine clearance; serum immunoglobulin G level); standard (intravenous [IV] hydration and anti‐motility agents) or experimental (nitazoxanide and IV immunoglobulin) treatment administered, dose and duration of treatment; route of immunoglobulin administration; enteral feeding; changes in immunosuppressive medications; and need for total parenteral nutrition (TPN).…”

Hepatitis E virus is an infrequent but potentially serious infection in allogeneic hematopoietic stem cell transplant recipients

“…In immunocompromised patients, norovirus is increasingly acknowledged as a cause of chronic and/or severe gastroenteritis. This has been described in patients after solid organ transplantation [128][129][130][131] , and in patients with hematological malignancy 120 and primary immunodeficiency disorders [132][133][134] . There is limited knowledge of norovirus in the HSCT setting.…”

Persistent elevation of aminotransferases in liver transplant in association with chronic norovirus infection

“…Treatment of chronic norovirus infection in immunocompromised host is not well established. Decreasing immunosuppression dosage, Nitazoxanide, IVIG, or oral immunoglobulin may be considered; although evidence of their effectiveness is limited, and further studies are necessary to determine optimal treatment [13,14].…”