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Late and atypical cytomegalovirus disease in solid-organ transplant recipients
M Slifkin1, P Tempesti, D D Poutsiaka
1Department of Geographic Medicine and Infectious Diseases, New England Medical Center and Tufts University School of Medicine, Boston, MA 02111, USA.
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.
Insights
Late-presenting cytomegalovirus (CMV) disease in organ transplant recipients is rare, often lacking typical symptoms like fever. This suggests a shift in CMV disease presentation post-transplant.
Area of Science:
- Transplant Medicine
- Infectious Diseases
- Virology
Background:
- Cytomegalovirus (CMV) disease commonly affects solid-organ transplant recipients 1-4 months post-transplant, typically presenting with fever and leukopenia.
- Established case definitions for CMV disease focus on early post-transplant presentations.
Observation:
- Five cases of late and atypical CMV disease were observed in heart, liver, and kidney transplant recipients between 6 months and 22 years post-transplant.
- Atypical features included absence of fever (3/5), elevated white blood cell counts (4/5), and normal platelet counts (4/5).
- Some patients had pulmonary CMV disease without hypoxia or chronic enterocolitis.
Findings:
- These late presentations occurred despite some patients receiving ganciclovir prophylaxis or being treated for rejection.
- The observed cases challenge the typical understanding of CMV disease timing and clinical manifestations.
- Risk factors included primary CMV infection and specific immunosuppressive therapies like muromonab-CD3.
Implications:
- The findings suggest a potential evolution in the epidemiology and clinical spectrum of CMV disease in transplant recipients.
- This necessitates re-evaluation of diagnostic criteria and monitoring strategies for CMV in the late post-transplant period.
- Changes in immunosuppression protocols and early CMV prevention may be influencing these atypical presentations.