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Zais IE, Sirotti A, Iesari S, Campioli E, Costantino A, Delbue S, Collini A, Guarneri A, Ambrogi F, Cacciola R, Ferraresso M, Favi E. Human cytomegalovirus-related gastrointestinal disease after kidney transplantation: A systematic review. Clin Transplant 2024; 38:e15218. [PMID: 38063324 DOI: 10.1111/ctr.15218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/14/2023] [Accepted: 11/27/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Human-cytomegalovirus (hCMV) infection involving the gastrointestinal tract represents a leading cause of morbidity and mortality among kidney transplant (KT) recipients (KTRs). Signs and symptoms of the disease are extremely variable. Prompt anti-viral therapy administration and immunosuppression modification are key factors for optimizing management. However, complex work-up strategies are generally required to confirm the preliminary diagnosis. Unfortunately, solid evidence and guidelines on this specific topic are not available. We consequently aimed to summarize current knowledge on post-KT hCMV-related gastrointestinal disease (hCMV-GID). METHODS We conducted a systematic review (PROSPERO ID: CRD42023399363) about hCMV-GID in KTRs. RESULTS Our systematic review includes 52 case-reports and ten case-series, published between 1985 and 2022, collectively reporting 311 cases. The most frequently reported signs and symptoms of hCMV-GID were abdominal pain, diarrhea, epigastric pain, vomiting, fever, and GI bleeding. Esophagogastroduodenoscopy and colonoscopy were the primary diagnostic techniques. In most cases, the preliminary diagnosis was confirmed by histology. Information on anti-viral prophylaxis were extremely limited as much as data on induction or maintenance immunosuppression. Treatment included ganciclovir and/or valganciclovir administration. Immunosuppression modification mainly consisted of mycophenolate mofetil or calcineurin inhibitor minimization and withdrawal. In total, 21 deaths were recorded. Renal allograft-related outcomes were described for 26 patients only. Specifically, reported events were acute kidney injury (n = 17), transplant failure (n = 5), allograft rejection (n = 4), and irreversible allograft dysfunction (n = 3). CONCLUSIONS The development of local and national registries is strongly recommended to improve our understanding of hCMV-GID. Future clinical guidelines should consider the implementation of dedicated diagnostic and treatment strategies.
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Affiliation(s)
| | - Alessandro Sirotti
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Samuele Iesari
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edoardo Campioli
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Costantino
- Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Serena Delbue
- Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milan, Italy
| | - Andrea Collini
- Renal Transplant Unit, Siena University Hospital, Siena, Italy
| | - Andrea Guarneri
- Department of Clinical Sciences and Community Health (DISCCO), Università degli Studi di Milano, Milan, Italy
| | - Federico Ambrogi
- Department of Clinical Sciences and Community Health (DISCCO), Università degli Studi di Milano, Milan, Italy
| | - Roberto Cacciola
- Dipartimento di Scienze Chirurgiche, Università di Roma Tor Vergata, Rome, Italy
| | - Mariano Ferraresso
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health (DISCCO), Università degli Studi di Milano, Milan, Italy
| | - Evaldo Favi
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health (DISCCO), Università degli Studi di Milano, Milan, Italy
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Kato K, Cooper M. Small bowel perforation secondary to CMV-positive terminal ileitis postrenal transplant. BMJ Case Rep 2019; 12:12/11/e231662. [PMID: 31772132 DOI: 10.1136/bcr-2019-231662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cytomegalovirus (CMV) infection of the gastrointestinal tract is common in immunosuppressed patients; however, small bowel perforation from tissue-invasive CMV disease after many years of immunosuppressive therapy is a rare complication requiring timely medical and surgical intervention. We report a case of a postrenal transplant patient who presented to the emergency department with severe lower abdominal pain with CT of the abdomen/pelvis revealing a small bowel perforation. He underwent an emergent laparoscopic right hemicolectomy, and his histopathology of the terminal ileum was positive for CMV disease. He was successfully treated with intravenous ganciclovir postoperatively. We discuss the pathophysiology, histopathological features and treatment of CMV infection.
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Affiliation(s)
- Kosuke Kato
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Michelle Cooper
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
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Development of a Predictive Model Using Endoscopic Features for Gastric Cytomegalovirus Infection in Renal Transplant Patients. Transplantation 2018; 103:998-1004. [PMID: 30507742 DOI: 10.1097/tp.0000000000002554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a common viral pathogen in transplant patients which often targets the stomach. However, the endoscopic characteristics of gastric CMV infection are not well established. We aimed to develop a predictive model using endoscopic findings for gastric CMV infection in renal transplant patients. METHODS A retrospective study of 287 kidney transplant recipients who underwent endoscopy with biopsy for suspected CMV infection from January 2006 to November 2015 at a tertiary referral hospital was performed. CMV infection was defined based on inclusion bodies in hematoxylin and eosin and immunohistochemical staining. Endoscopic and clinical parameters related to gastric CMV infection were selected by univariate analyses. Multivariate logistic regression was used to create a predictive model from β-coefficients. RESULTS CMV was present in 107 (37.7%) of the 287 patients. Multivariate analysis found age (odds ratio [OR], 0.964; 95% confidence interval [CI], 0.938-0.99; P = 0.008), erosions with surface exudate (OR, 5.34; 95% CI, 2.687-10.612; P < 0.001), raised shape of erosions (OR, 3.957; 95% CI, 1.937-8.083; P < 0.001), and antral location of ulcers (OR, 15.018; 95% CI, 5.728-39.371; P < 0.001) as independent predictive factors for gastric CMV infection. Using the predictive model created from this analysis, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 71.03%, 85.56%, 74.51%, 83.24%, and 80.14%, respectively. The area under the receiver operating characteristic curve of this model for detecting CMV infection was 0.850 (95% CI, 0.803-0.889; P < 0.001). CONCLUSIONS The predictive model with typical endoscopic findings may be useful for detecting gastric CMV infection in renal transplant patients.
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Arnold M, Itzikowitz R, Young B, Machoki SM, Hsiao NY, Pillay K, Alexander A. Surgical manifestations of gastrointestinal cytomegalovirus infection in children: Clinical audit and literature review. J Pediatr Surg 2015; 50:1874-9. [PMID: 26265193 DOI: 10.1016/j.jpedsurg.2015.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 06/17/2015] [Accepted: 06/22/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Gastrointestinal sequelae of cytomegalovirus are rare, usually associated with significant immune compromise, and carry a high morbidity and mortality. Gastrointestinal disease frequently requires surgical intervention for diagnosis and management. AIM The aim of the study is to evaluate the incidence, presentation and management of gastrointestinal cytomegalovirus disease in a pediatric population. METHOD Between January 2003 and June 2011, a retrospective folder review was conducted of all symptomatic children with proven CMV disease, presenting to the surgical service. Eligible patients were identified using the surgical, histopathology and serology databases. RESULTS Thirty-eight patients (1.8/1000 surgical admissions) were identified with a median presenting age of 5months (range 3days-12years). Esophagitis (n=18) and small bowel disease (n=16) predominated, but CMV was seen throughout the gastrointestinal tract. Risk factors included HIV infection (n=21, 55%) and recent gastrointestinal surgery or infection (n=10, 26%). Characteristic multiple jejunoileal perforations were seen in six patients. Compared to upper GIT disease, intestinal involvement was associated with younger age and doubled mortality. In HIV-infected children, median CD4 (%) was lower in intestinal compared to upper gastrointestinal disease. Morbidities included anastomotic breakdowns (5), anastomotic strictures (3), relook laparotomies (10), resistant esophageal strictures (5) and prolonged parenteral nutrition (5). Anti-CMV drugs were given in 63%. Overall mortality was 32% (12/38) and was associated with lower GIT disease. CONCLUSION Invasive CMV gastrointestinal disease in our children was predominantly HIV-associated, or followed a major lower gastrointestinal inflammatory insult in infants younger than 6months. Successful therapy requires a high index of suspicion of active CMV disease to allow early implementation of CMV viral load control and aggressive treatment of the underlying immune impairment. Multiple surgical interventions are often required for both tissue diagnosis and management of acute and chronic complications. CMV-viral-load-tailored anti-CMV therapy is supported by recent literature.
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Affiliation(s)
- M Arnold
- Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - R Itzikowitz
- Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - B Young
- Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - S M Machoki
- Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - N Y Hsiao
- Division of Medical Virology, National Health Laboratory Service/University of Cape Town, Cape Town, South Africa
| | - K Pillay
- Department of Histopathology, NHLS, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - A Alexander
- Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Cotter MB, AbuShanab A, Merriman R, McCormick A, Sheahan K. Coeliac-like duodenal pathology in orthotopic liver transplant patients on mycophenolic acid therapy. Histopathology 2015; 66:500-7. [PMID: 25195696 DOI: 10.1111/his.12541] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 08/29/2014] [Indexed: 12/20/2022]
Abstract
AIMS Diarrhoea following orthotopic liver transplantation (OLT) is a significant clinical problem associated with mycophenolic acid (MPA). The histological injury pattern associated with MPA in the large bowel is well documented in the literature; however, that in the duodenum is less extensively documented. The aim of this study was to investigate the histological spectrum of duodenal injury specifically in symptomatic OLT patients on MPA, and to compare this with the spectrum in patients with coeliac disease and in normal controls. METHODS AND RESULTS We reviewed our pathology database for all duodenal biopsies from patients on the OLT list over a period of 19 years. Medical records, anti-tissue transglutaminase IgA serology and histology were reviewed. Of the 667 patients who underwent endoscopy, 127 had duodenal biopsies (152 biopsies). Of these, 87.5% were normal. Sixteen showed abnormal histology, and seven (43.8%) of these were on MPA at the time of biopsy. Significant features included coeliac-like changes (shortened villi and increased intraepithelial lymphocyte counts), and novel findings included increased endocrine cell counts, apoptotic counts and lamina propria eosinophil counts in comparison with normal duodenal biopsies. CONCLUSIONS Pathologists should be aware of the features of MPA-associated duodenal injury, including coeliac-like changes and increased apoptotic counts. In those with abnormal histology, discontinuation or a reduction in the dose of MPA should be discussed.
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Affiliation(s)
- Maura B Cotter
- Department of Histopathology, Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Kazanji N, Davila F, Manickam P, Wang Y, Bossory L. A case of invasive cytomegalovirus duodenitis in an immunosuppressed patient 15 months after renal transplantation. Infection 2015; 43:383-5. [PMID: 25582982 DOI: 10.1007/s15010-014-0714-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 12/18/2014] [Indexed: 12/12/2022]
Abstract
Cytomegalovirus (CMV) remains one of the most important infections in kidney transplantation. Only a handful of images have been reported in the literature thus far. We present classic pathologic and gross images of CMV duodenitis in an immunosuppressed patient more than one year post-renal transplantation.
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Affiliation(s)
- N Kazanji
- Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Beaumont Health System, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA,
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Lempinen M, Halme L, Arola J, Honkanen E, Salmela K, Lautenschlager I. HHV-6B is frequently found in the gastrointestinal tract in kidney transplantation patients. Transpl Int 2012; 25:776-82. [DOI: 10.1111/j.1432-2277.2012.01502.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Sipponen T, Turunen U, Lautenschlager I, Nieminen U, Arola J, Halme L. Human herpesvirus 6 and cytomegalovirus in ileocolonic mucosa in inflammatory bowel disease. Scand J Gastroenterol 2011; 46:1324-33. [PMID: 21879802 DOI: 10.3109/00365521.2011.605466] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Reactivation of a latent cytomegalovirus (CMV) may occur in inflammatory bowel disease (IBD). Data of human herpesvirus 6 (HHV-6)--a close relative to CMV--in active IBD are scarce. The aim of this study was to detect HHV-6 and CMV antigens in the mucosa of active and inactive IBD. MATERIAL AND METHODS 79 IBD patients (47 ulcerative colitis (UC) and 32 Crohn's disease (CD)) were recruited and endoscopic and histological disease activity was scored. Control group consisted of 15 non-IBD patients with normal colonoscopy. Immunohistochemical stainings for HHV-6B and CMV antigens were performed on biopsy specimens from the ileum and colorectum. The intensity of HHV-6B and CMV expression was graded as negative, mild, moderate, or intense. RESULTS HHV-6B antigen was positive in 35 (44%) and CMV in 64 (81%). Of controls, 6 (40%) were mildly positive for HHV-6 and 6 (40%) for CMV. In IBD, both CMV and HHV-6B intensity correlated with endoscopic disease severity (CMV p = 0.010 and HHV-6 p = 0.048). Simultaneous HHV-6B and CMV antigen expression occurred in 29 (37%) and associated with endoscopic activity (p = 0.006) and to a number of immunosuppressives (p = 0.033). A significant difference in HHV-6B positivity was found between endoscopically active and inactive UC (p = 0.040). Both CMV and HHV-6B intensity correlated with histological severity in the rectal biopsy specimens (for CMV p = 0.040 and for HHV-6B p = 0.027). CONCLUSIONS Both viruses occurred ubiquitously in the IBD mucosa. Coexistence of viruses was common and associated with disease activity and use of immunosuppressives. HHV-6B intensity correlated with endoscopic severity in UC.
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Affiliation(s)
- Taina Sipponen
- Department of Medicine, Division of Gastroenterology, Helsinki University Central Hospital, Helsinki, Finland.
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Cytomegalovirus infection presenting as isolated inflammatory polyps of the gastrointestinal tract. Pathology 2011; 43:440-6. [DOI: 10.1097/pat.0b013e3283485e51] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Weclawiak H, Ould-Mohamed A, Bournet B, Guilbeau-Frugier C, Fortenfant F, Muscari F, Sallusto F, Dambrin C, Esposito L, Guitard J, Abbal M, Rostaing L, Kamar N. Duodenal villous atrophy: a cause of chronic diarrhea after solid-organ transplantation. Am J Transplant 2011; 11:575-82. [PMID: 21299830 DOI: 10.1111/j.1600-6143.2010.03423.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Persistent diarrhea is commonly observed after solid organ transplantation (SOT). A few cases of mycophenolate mofetil (MMF)-induced duodenal villous atrophy (DVA) have been previously reported in kidney-transplant patients with chronic diarrhea. Herein, we report on the incidence and characteristics of DVA in SOT patients with chronic diarrhea. One hundred thirty-two SOT patients with chronic diarrhea underwent an oesophago-gastroduodenoscopy (OGD) and a duodenal biopsy after classical causes of diarrhea have been ruled out. DVA was diagnosed in 21 patients (15.9%). It was attributed to mycophenolic acid (MPA) therapy in 18 patients (85.7%) (MMF [n = 14] and enteric-coated mycophenolate sodium [n = 4]). MPA withdrawal or dose reduction resulted in diarrhea cessation. The incidence of DVA was significantly higher in patients with chronic diarrhea receiving MPA compared to those who did not (24.6% vs. 5.1%, p = 0.003). DVA was attributed to a Giardia lamblia parasitic infection in two patients (9.5%) and the remaining case was attributed to azathioprine. In these three patients, diarrhea ceased after metronidazole therapy or azathioprine dose reduction. In conclusion, DVA is a frequent cause of chronic diarrhea in SOT recipients. MPA therapy is the most frequent cause of DVA. An OGD should be proposed to all transplant recipients who present with persistent diarrhea.
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Affiliation(s)
- H Weclawiak
- Department of Nephrology, Dialysis and Organ Transplantation, CHU Rangueil, Toulouse, France
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