Varicella zoster virus and cytomegalovirus co-infection in a live related kidney transplant recipient: a case report

Abstract

Infections are common complications in kidney transplant recipients owing to the lifelong immunosuppression. Cytomegalovirus (CMV) and varicella zoster virus (VZV) infections are quite common in the posttransplant period. Coinfection with both however has been reported only once. The immunomodulatory effect of CMV makes their interaction with other organisms like VZV potentially sinister. This is a case of a female who developed coinfection with HZV and CMV in the first month following a live related kidney transplantation. A 32-year-old female, with a presumptive diagnosis of glomerulonephritis, hypertension and chronic kidney (CKD) underwent live-related kidney transplantation from her mother following a period of hemodialysis for 8 months. There was one haplotype match and both B and T cell cross matches were negative. CMV DNA was undetected in both donor and recipient prior to transplantation. Immunosuppression consisted of prednisolone, mycophenolate sodium and tacrolimus. The surgery went well, yielding a urine output of 4-6 L/day. However, the serum creatinine did not reach baseline, with a nadir of 2 mg/dL. On the postoperative day (POD) 25, she developed low grade fever, which was followed 2 days later by pain and vesicular eruptions involving the dermatomal distribution of the ophthalmic division of the trigeminal nerve (V1) on the left, resembling herpes zoster ophthalmicus. CMV polymerase chain reaction (PCR) yielded 300 copies/mL. Treatment was immediately started with oral Acyclovir, which was later switched to oral Ganciclovir, along with acyclovir ointment and ganciclovir eye gel. The patient's fever subsided and the skin lesions resolved over a period of 2 weeks. Serum creatinine came down to baseline. Infections after kidney transplant is often difficult to diagnose, manage and cure, especially in the immediate posttransplant period. In our case, early diagnosis and treatment resulted in a good outcome.