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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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Higgs J, Strand A, Goyal N, Kohli R, Pejchal M, Perrone R, Yoo J, Dad T. A 51-Year-Old Renal Transplant Recipient With Abdominal Pain. Clin Infect Dis 2021; 71:453-454. [PMID: 32652030 DOI: 10.1093/cid/ciz873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- James Higgs
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Andrew Strand
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Nitender Goyal
- Tufts Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Rakhi Kohli
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Martina Pejchal
- Tufts Surgical/GI Pathology Division, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ronald Perrone
- Tufts University School of Medicine and Division of Nephrology and Clinical and Translational Research Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - James Yoo
- Division of General and GI surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Taimur Dad
- Associate Nephrology Fellowship Director, Tufts Medical Center, Boston, Massachusetts, USA
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Zeidan JH, Kamionek M, Noell BC, Schmeltzer PA, deLemos AS, Gajurel K. Late onset CMV disease presenting as a colonic stricture in a liver transplant recipient. Transpl Infect Dis 2020; 22:e13259. [PMID: 32034980 DOI: 10.1111/tid.13259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/19/2019] [Accepted: 02/02/2020] [Indexed: 11/28/2022]
Abstract
Cytomegalovirus (CMV) is a common opportunistic infection in solid organ transplant (SOT) recipients in the first 6 months after transplant. Late onset CMV infection or disease outside the classical risk period is uncommon and can present with atypical signs and symptoms. Here, we report a case of late onset CMV presenting as a colonic stricture more than 10 years after liver transplantation in the absence of traditional CMV risk factors. We also briefly review CMV colitis presenting as a mass or stricture in SOT recipients.
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Affiliation(s)
- Joseph H Zeidan
- Division of Gastroenterology and Hepatology, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | | | - Bennett C Noell
- Transplant Center, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Paul A Schmeltzer
- Center for Liver Diseases and Liver transplantation, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Andrew S deLemos
- Center for Liver Diseases and Liver transplantation, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Kiran Gajurel
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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Papadimitriou G, Koukoulaki M, Vardas K, Florou E, Argyrakos T, Lakiotis G, Apostolou T, Drakopoulos S. Small bowel obstruction caused by inflammatory cytomegalovirus tumor in a renal transplant recipient: report of a rare case and review of the literature. Transpl Infect Dis 2012; 14:E111-5. [DOI: 10.1111/j.1399-3062.2012.00784.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Revised: 05/09/2012] [Accepted: 05/27/2012] [Indexed: 02/04/2023]
Affiliation(s)
- G. Papadimitriou
- First Department of Surgery and Transplant Unit; Evangelismos General Hospital; Athens; Greece
| | - M. Koukoulaki
- First Department of Surgery and Transplant Unit; Evangelismos General Hospital; Athens; Greece
| | - K. Vardas
- First Department of Surgery and Transplant Unit; Evangelismos General Hospital; Athens; Greece
| | - E. Florou
- First Department of Surgery and Transplant Unit; Evangelismos General Hospital; Athens; Greece
| | - T. Argyrakos
- Department of Pathological Anatomy; Evangelismos General Hospital; Athens; Greece
| | - G. Lakiotis
- Second Department of Surgery; Evangelismos General Hospital; Athens; Greece
| | - T. Apostolou
- Department of Nephrology; Evangelismos General Hospital; Athens; Greece
| | - S. Drakopoulos
- First Department of Surgery and Transplant Unit; Evangelismos General Hospital; Athens; Greece
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6
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Kelesidis T, Tozzi S, Mitty R, Worthington M, Fleisher J. Cytomegalovirus pseudotumor of the duodenum in a patient with AIDS: an unrecognized and potentially treatable clinical entity. Int J Infect Dis 2010; 14:e274-82. [PMID: 19695917 PMCID: PMC8055438 DOI: 10.1016/j.ijid.2009.04.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Revised: 04/04/2009] [Accepted: 04/08/2009] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) is a common pathogen affecting the gastrointestinal tract in patients with AIDS. We report a case of CMV-induced pseudotumor of the duodenum in a patient with AIDS and review other reported cases of CMV-induced pseudotumors in the gastrointestinal tract. CMV-induced pseudotumor in patients with AIDS is an exceptionally rare clinical entity, and to our knowledge no reports have previously summarized this clinical entity. METHODS All previous cases included in our literature review were found using a PubMed search (1980-November 2008) of the English-language medical literature applying the terms 'CMV infection', 'inflammatory mass', 'pseudotumor', and 'gastrointestinal tract'. The references cited in these articles were examined to identify additional reports. RESULTS Although CMV-induced duodenitis has been described in patients with HIV infection, to our knowledge CMV-induced pseudotumor of the duodenum has not been previously reported in the literature. We describe the first case of an AIDS patient with CMV pseudotumor responding to oral treatment with valganciclovir with complete resolution of the CMV mass. Among reports of non-duodenal pseudotumor reported in the English literature, we found only 14 cases of CMV-induced gastrointestinal pseudotumors in HIV-positive patients. The clinical manifestations, pathologic findings of the CMV pseudotumors, as well as the treatment and outcome of these HIV patients are reviewed. CONCLUSION CMV pseudotumor should be included in the differential diagnosis of gastrointestinal mass lesions in AIDS patients and in other immunocompromised patients. The tumor often responds to antiviral therapy, but resolution of a CMV mass as a result of oral antiviral therapy has not been previously described. Since pseudotumors secondary to CMV often respond to medical treatment, it is important that the physicians treating severely immunocompromised patients are aware of this entity.
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Affiliation(s)
- Theodoros Kelesidis
- Division of Infectious Diseases, Department of Medicine, Caritas St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA 02135, USA.
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Lempinen M, Halme L, Sarkio S, Arola J, Honkanen E, Turunen U, Salmela K, Lautenschlager I. CMV findings in the gastrointestinal tract in kidney transplantation patients, patients with end-stage kidney disease and immunocompetent patients. Nephrol Dial Transplant 2009; 24:3533-9. [DOI: 10.1093/ndt/gfp408] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Dumoulin A, Boulmerka H, Tran Van Nhieu J, Lang P, Baron C. Severe recurrent cytomegalovirus disease revealed by a colocutaneous fistula in a kidney transplant recipient. Transpl Infect Dis 2008; 5:147-50. [PMID: 14617304 DOI: 10.1034/j.1399-3062.2003.00014.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Intestinal disorders are classical complications of cytomegalovirus (CMV) infection in kidney transplant recipients (Helderman JH, Goral S. Gastrointestinal complications of transplant immunosuppression. J Am Soc Nephrol 2002: 13: 277-287). Severe ulcerative colitis that is sometimes lethal has been reported (Foucar E, Mukai K, Foucar K, Sutherland DE, Van Buren CT. Colon ulceration in lethal cytomegalovirus infection. Am J Clin Pathol 1981: 76: 788-801 and Frankel AH, Barker F, Williams G, Benjamin IS, Lechler R, Rees AJ. Neutropenic enterocolitis in a renal transplant patient. Transplantation 1991: 52: 913-914). The immunosuppressive drugs currently used, and notably mycophenolate mofetil (Cellcept), cause significant changes in the incidence, duration, and viral load of CMV infections with severe atypical forms of CMV disease (De Maar EF, Verschuuren EA, Homan vd Heide JJ, et al. Effects of changing immunosuppressive regimen on the incidence, duration and viral load of cytomegalovirus infection in renal transplantation: a single center report. Transpl Infect Dis 2002: 4: 17-24 and Perez Valentin MA, Cofan F, Sole M, et al. Atypical cytomegalovirus in renal transplantation: a new form of presentation. Nefrologia 2002: 22: 381-385). This report describes a patient who suffered from several episodes of colitis due to an unusual and late-appearing CMV infection.
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Affiliation(s)
- A Dumoulin
- Service de Néphrologie et de Transplantation, Hôpital Henri Mondor, Créteil, France.
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Sugimoto T, Soumura M, Kawasaki M, Kawai H, Uzu T, Nishio Y, Tani T, Kashiwagi A. Cytomegalovirus-induced small-bowel hemorrhage in a patient with nonsystemic vasculitic neuropathy. Clin Rheumatol 2006; 25:575-6. [PMID: 16404493 DOI: 10.1007/s10067-005-0187-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Revised: 12/04/2005] [Accepted: 12/06/2005] [Indexed: 10/25/2022]
Abstract
A 73-year-old man who was being treated with corticosteroids for nonsystemic vasculitic neuropathy developed small-bowel hemorrhage after ileostomy for ileus. Immunohistochemical staining for cytomegalovirus (CMV) antigen in the ulcer in the resected ileum was positive; thus, cytomegalovirus infection of the small intestine caused his gastrointestinal manifestations. Cytomegalovirus infection should be considered in the differential diagnosis of gastrointestinal diseases in patients with collagen vascular diseases receiving immunosuppressive agents.
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Affiliation(s)
- Toshiro Sugimoto
- Department of Medicine, Shiga University of Medical Science, Seta, Shiga, 520-2192, Japan.
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Abstract
Acute pseudo-obstruction may manifest clinically in one of three forms--acute gastroparesis, ileus, and acute colonic pseudo-obstruction (Ogilvie's syndrome). Though formerly associated primarily with the postoperative state, these entities are increasingly recognized in association with a wide variety of major medical problems. There are few controlled studies to guide the clinician in the management of these disorders. Treatment remains largely empirical, and time-honored, based primarily on "bowel rest," nasogastric decompression, and supportive care. While a wide variety of pharmacologic approaches have been advocated, few have been subjected to, or survived, the rigors of a properly controlled trial. Neostigmine is a notable exception, and has been shown to be effective in Ogilvie's syndrome. Perforation is a significant threat in megacolon; colonoscopic, or surgical decompression may, therefore, be indicated. Both are associated with significant risks in this context, but may prevent progression to perforation with its attendant mortality. New approaches seek to exploit current concepts in the pathophysiology of ileus and megacolon but have not, as yet, achieved efficacy in human studies.
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Shapiro AMJ, Bain VG, Preiksaitis JK, Ma MM, Issa S, Kneteman NM. Ogilvie's syndrome associated with acute cytomegaloviral infection after liver transplantation. Transpl Int 2000. [DOI: 10.1111/j.1432-2277.2000.tb01034.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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12
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Abstract
Intestinal obstruction, a disorder that afflicts both children and adults, is associated with significant morbidity. Early recognition and appropriate management can prevent life-threatening complications; however, considerable controversies exist regarding the ideal method of diagnosis and treatment. This article provides a comprehensive overview of risk factors for small and large bowel obstruction. The pathophysiologic process is related to the clinical findings. A summary of diagnostic methods with an evaluation of their relative merit is presented. Preventive, and medical, surgical, and palliative therapies are described, with an emphasis on the actions that an advanced practice nurse can implement.
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Affiliation(s)
- B K Shelton
- Johns Hopkins Oncology Center, Baltimore, Maryland, USA.
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Sheppard D, McPhee D, Darke C, Shrethra B, Moore R, Jurewitz A, Gray A. Predicting cytomegalovirus disease after renal transplantation: an artificial neural network approach. Int J Med Inform 1999; 54:55-76. [PMID: 10206429 DOI: 10.1016/s1386-5056(98)00169-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Outcome prediction is becoming increasingly important in medicine, but when a resource is scarce the need for accurate prediction becomes acute. Prediction based on biostatistical models has been in use for many years, but in areas such as renal transplantation their results have been disappointing. Recently however, there has been growing interest in the use of artificial neural networks for prediction. The creation of a large database containing high quality data on renal transplantation patients in Wales offers an ideal opportunity to research a new area viz., the ability of these techniques to accurately predict outcomes such as the appearance of disease in transplant recipients or the time to graft failure. This paper describes the use of neural networks to identify patients who risk the development of cytomegalovirus disease--a significant cause of mortality and morbidity in these patients. The neural networks we examined produced overall correct classifications well in excess of 80% in each of the two groups involved, diseased and non-diseased. These predictions are a considerable improvement on current methods and encourage the belief that renal transplantation data may respond well to analysis by neural networks.
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Affiliation(s)
- D Sheppard
- Department of Computer Studies, University of Glamorgan, Pontypridd, Mid Glamorgan, UK
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Crespo MG, Arnal FM, Gómez M, Monserrat L, Suarez F, Rodríguez JA, Paniagua MJ, Cuesta M, Juffé A, Castro-Beiras A. Cytomegalovirus colitis mimicking a colonic neoplasm or ischemic colitis 4 years after heart transplantation. Transplantation 1998; 66:1562-5. [PMID: 9869101 DOI: 10.1097/00007890-199812150-00023] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) colitis is a polymorphous disease presenting in immunodepressed patients in a variety of clinical forms that can delay diagnosis and therapy. We report the case of a patient who presented with abdominal pain 4 years after heart transplantation; clinical and x-ray findings were suggestive of a neoplastic or ischemic stenosis, and histopathological examination likewise initially suggested an ischemic etiology. METHODS Tissue samples were fixed in 10% formaldehyde, embedded in paraffin, cut, and stained with hematoxylin/eosin and periodic acid-Schiff-Alcian Blue. Immunohistochemistry with monoclonal antibodies was performed using an indirect immunoperoxidase method. RESULTS CMV colitis was eventually diagnosed and resolved with surgery and specific anti-CMV therapy. CONCLUSIONS CMV colitis should be suspected in any heart transplant patient with signs or symptoms of abdominal pathology, even without classical signs or symptoms of CMV infection. If stenotic lesions are present, surgery may be required not only to remove the obstruction but also to rule out malignancy.
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Affiliation(s)
- M G Crespo
- Department of Pathology, Hospital Juan Canalejo, La Coruña, Spain
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