Very-late-onset cytomegalovirus disease: a case-report and review of the literature

Abstract

BackgroundCytomegalovirus (CMV) infection remains one of the most common and feared complications of transplantation, justifying prophylaxis or preemptive strategies guided by donor and recipient CMV serostatus. In case of seronegative donor and recipient (D−/R−), no prophylaxis is recommended. Late-onset CMV disease is usually defined as occurring after prophylaxis discontinuation in D+/R− transplant patients.Case presentationWe are reporting the case of a D−/R− kidney Caucasian transplant recipient presenting with CMV primoinfection 12 years after renal transplant, and discuss the role of a secondary prophylaxis so late after transplantation.ConclusionsPrimary infections leading to late-onset CMV disease in transplant patients remain rare. Recurrent disease has been described in as many as one-third of these patients. A systematic secondary prophylaxis in this particular group of patients is questionable.

Very late‐onset cytomegalovirus disease with ganciclovir resistance >15 years following renal transplantation

“…Key interventions in preventing de novo CMV infection revolve around behavioral modifications to reduce exposure, similar to preventing CMV in seronegative pregnant women, and the use of leukocyte deplete and/or CMV‐seronegative blood products. The limited literature around very late CMV disease demonstrates vast variation in clinical presentation 1,4–9 and should always remain in the differential diagnosis in any illness post‐transplantation.…”

“…Advances in the diagnosis, monitoring, and therapeutics have resulted in significantly improved outcomes from CMV disease 1–3 . However, with these advances there has been a change in the epidemiology of CMV disease with an increasing trend toward “late‐onset” CMV disease, more atypical disease presentations, and increasing rates of antiviral resistance 3–12 . Due to widespread use of valganciclovir prophylaxis, the timing of CMV disease has shifted to after the cessation of antiviral prophylaxis, with “delayed”‐onset CMV occurring most frequently in the 3‐12 months post–solid organ transplantation (SOT) 3–9 .…”

“…However, with these advances there has been a change in the epidemiology of CMV disease with an increasing trend toward “late‐onset” CMV disease, more atypical disease presentations, and increasing rates of antiviral resistance 3–12 . Due to widespread use of valganciclovir prophylaxis, the timing of CMV disease has shifted to after the cessation of antiviral prophylaxis, with “delayed”‐onset CMV occurring most frequently in the 3‐12 months post–solid organ transplantation (SOT) 3–9 . “Late”‐onset CMV has been defined as occurring more than 12 months after transplantation 3–9 and is becoming increasingly important as 10‐year graft survival rates for renal transplant are approaching 75% 13…”

“…Due to widespread use of valganciclovir prophylaxis, the timing of CMV disease has shifted to after the cessation of antiviral prophylaxis, with “delayed”‐onset CMV occurring most frequently in the 3‐12 months post–solid organ transplantation (SOT) 3–9 . “Late”‐onset CMV has been defined as occurring more than 12 months after transplantation 3–9 and is becoming increasingly important as 10‐year graft survival rates for renal transplant are approaching 75% 13…”

Splenectomy for ABO-Incompatible Kidney Transplantation and Very Late-Onset Cytomegalovirus Disease

“…Cytomegalovirus (CMV) is the most dangerous viral pathogen after kidney transplants, and CMV disease usually occurs during the first 3 months of transplantation [8]. Reports have been made on very late-onset CMV disease that developed appropriately 10 years after transplantation [9]. Splenectomy may therefore affect the incidence of CMV disease at a very late stage in ABO-incompatible kidney transplant recipients.…”