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Jorgenson MR, Parajuli S, Kleiboeker HL, Felix DC, Astor BC, Saddler CM, Smith JA, Mandelbrot DA. Incidence and outcomes of fever of unknown origin after kidney transplant in the modern era. Clin Transplant 2024; 38:e15217. [PMID: 38078682 DOI: 10.1111/ctr.15217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/08/2023] [Accepted: 11/21/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND While presumably less common with modern molecular diagnostic and imaging techniques, fever of unknown origin (FUO) remains a challenge in kidney transplant recipients (KTRs). Additionally, the impact of FUO on patient and graft survival is poorly described. METHODS A cohort of adult KTRs between January 1, 1995 and December 31, 2018 was followed at the University of Wisconsin Hospital. Patients transplanted from January 1, 1995 to December 31, 2005 were included in the "early era"; patients transplanted from January 1, 2006 to December 31, 2018 were included in the "modern era". The primary objective was to describe the epidemiology and etiology of FUO diagnoses over time. Secondary outcomes included rejection, graft and patient survival. RESULTS There were 5590 kidney transplants at our center during the study window. FUO was identified in 323 patients with an overall incidence rate of .8/100 person-years. Considering only the first 3 years after transplant, the incidence of FUO was significantly lower in the modern era than in the early era, with an Incidence Rate Ratio (IRR) per 100 person-years of .48; 95% CI: .35-.63; p < .001. A total of 102 (31.9%) of 323 patients had an etiology determined within 90 days after FUO diagnosis: 100 were infectious, and two were malignancies. In the modern era, FUO remained significantly associated with rejection (HR = 44.1; 95% CI: 16.6-102; p < .001) but not graft failure (HR = 1.21; 95% CI: .68-2.18; p = .52) total graft loss (HR = 1.17; 95% CI: .85-1.62; p = .34), or death (HR = 1.17; 95% CI: .79-1.76; p = .43. CONCLUSIONS FUO is less common in KTRs during the modern era. Our study suggests infection remains the most common etiology. FUO remains associated with significant increases in risk of rejection, warranting further inquiry into the management of immunosuppressive medications in SOT recipients in the setting of FUO.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Hanna L Kleiboeker
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Daniel C Felix
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Brad C Astor
- Department of Medicine and Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Christopher M Saddler
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Jeannina A Smith
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
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Yeom GE, Lim SH, Kim JH, Ahn YH, Kim H, Ha J, Kim HY, Kang HG. Gastrointestinal involvement of passenger lymphocyte syndrome followed by minor ABO-incompatible renal transplantation: A case report. Pediatr Transplant 2023; 27:e14556. [PMID: 37300335 DOI: 10.1111/petr.14556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/02/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND People with group O blood are considered universal organ donors compatible with any other blood group. However, in the case of minor ABO-incompatible transplantation, immune-mediated hemolysis may occur due to concomitant transfer of donor B lymphocytes together with the allograft. These passenger lymphocytes can produce antibodies in the recipients erythrocytes, causing hemolytic anemia known as passenger lymphocyte syndrome (PLS). METHODS A retrospective chart review was performed. RESULTS A 6-year-old boy (A+) underwent transplantation of a kidney from his father (O+). On postoperative day (POD) 6, the patient developed fever with no explainable causes. On POD 11, he presented with abdominal pain, hematochezia, and severe diarrhea, with sudden hemolytic anemia. Since then, GI symptoms have continued. On POD 20, direct antiglobulin test (DAT) was positive, and the anti-A IgM/G titer was 2/32. The results of the anti-A antibody elution test were strongly positive (3+). These findings highly suggested PLS. On the same day, the GI symptoms suddenly worsened, and laboratory findings showed hemolysis and thrombocytopenia with disseminated intravascular coagulation (DIC). Abdominal computed tomography (CT) scans suggested ischemic colitis of venous origin, and the patient underwent segmental colectomy with ileostomy formation on POD 23. To remove the anti-A antibodies, the patient underwent therapeutic plasma exchange (TPE) five times until the DAT and anti-A elution test were negative. CONCLUSIONS We report a case of gastrointestinal involvement of PLS that occurred after minor ABO-incompatible kidney transplantation. This is the first report of ischemic colitis as an atypical manifestation of PLS.
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Affiliation(s)
- Gyeong Eun Yeom
- Departments of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Seon Hee Lim
- Department of Pediatrics, Pusan National University Children's Hospital and School of Medicine, Yangsan, Republic of Korea
| | - Ji Hyun Kim
- Departments of Pediatrics, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Yo Han Ahn
- Departments of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Hyungsuk Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jongwon Ha
- The Transplantation Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, South Korea
| | - Hee Gyung Kang
- Departments of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
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3
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Chua YY, Ho QY, Ngo NT, Krishnamoorthy TL, Thangaraju S, Kee T, Wong HM. Cytomegalovirus-associated pseudomembranous colitis in a kidney transplant recipient. Transpl Infect Dis 2021; 23:e13694. [PMID: 34288307 DOI: 10.1111/tid.13694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/02/2021] [Accepted: 06/29/2021] [Indexed: 01/03/2023]
Abstract
Pseudomembranous colitis (PMC) is classically associated with Clostridium difficile infection. We report a rare case of cytomegalovirus (CMV)-associated PMC in a 52-year-old female patient who had undergone kidney transplantation more than 20 years ago and was on low dose prednisolone and ciclosporin. She presented with an acute history of fever, lethargy, vomiting and diarrhoea on admission. Computed tomography of the abdomen showed extensive colitis, and colonoscopy revealed extensive pseudomembrane formation. Multiple tests for Clostridium difficile and other common microbiological causes of colitis were negative. CMV DNAemia and colonic biopsies confirmed the diagnosis of CMV colitis. The patient responded to prompt CMV treatment, as demonstrated by clinical, endoscopic, and histological response. While CMV is a common pathogen in the solid organ transplant population that is familiar to most transplant physicians, it may present atypically as PMC. Here, we review the literature on CMV-associated PMC and its relevance to solid organ transplant recipients. To our knowledge, this is the first reported case of CMV-associated PMC in a kidney transplant recipient.
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Affiliation(s)
- Yi Yi Chua
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore.,SingHealth-Duke NUS Transplant Centre, SingHealth, Singapore
| | - Nye Thane Ngo
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Thinesh Lee Krishnamoorthy
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,SingHealth-Duke NUS Transplant Centre, SingHealth, Singapore
| | - Sobhana Thangaraju
- Department of Renal Medicine, Singapore General Hospital, Singapore.,SingHealth-Duke NUS Transplant Centre, SingHealth, Singapore
| | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore.,SingHealth-Duke NUS Transplant Centre, SingHealth, Singapore
| | - Hei Man Wong
- Department of Infectious Diseases, Singapore General Hospital, Singapore
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Surapaneni BK, Priyadarshni S, Choksi V, Sorathia S, Kasmin F. A Rare Case of Cytomegalovirus in the Gut in an Immunocompetent Host With Ischemic Colitis. Cureus 2020; 12:e9432. [PMID: 32742891 PMCID: PMC7389188 DOI: 10.7759/cureus.9432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Cytomegalovirus (CMV) infections are typically seen in individuals with immunosuppressive conditions such as malignancies, HIV/AIDS, and organ transplantation, and in patients on chemotherapy or steroids. Recurrent disease can occur if the virus reactivates due to disruption of immunity due to factors such as older age or immunosuppressive drugs. CMV is common, with a seroprevalence (CMV IgG-positive) of 40-100 % in adults, increasing with age. It has been reported that inflammatory bowel disease in remission can be exacerbated by CMV colitis or complicate steroids refractory colitis flare. For this reason, steroids should be cautiously started if clinical suspicion is high for CMV. We report a unique case of CMV colitis associated with severe ischemic colitis in an immunocompetent patient, with an excellent response to management with antiviral therapy.
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Abstract
PURPOSE OF REVIEW The review summarizes the epidemiology, risk factors, clinical presentation, diagnosis and management of the most important etiologic agents of infectious diarrhea in critically ill transplant recipients. RECENT FINDINGS Diarrhea, frequently caused by infectious pathogens, can cause significant morbidity and mortality in transplant recipients. Diarrhea can lead to severe dehydration, acute renal failure, medication toxicity, rejection, graft-versus-host disease and impairs patients' quality of life. Opportunistic infectious pathogens can pose significant diagnostic and therapeutic challenges in immunocompromised hosts. SUMMARY In transplant recipients, it is vital to differentiate infectious from noninfectious diarrhea to adequately manage their therapeutic approach. Supportive measures and reduction in immunosuppression are essential for the treatment management.
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7
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Kalil AC, Sandkovsky U, Florescu DF. Severe infections in critically ill solid organ transplant recipients. Clin Microbiol Infect 2018; 24:1257-63. [PMID: 29715551 DOI: 10.1016/j.cmi.2018.04.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/13/2018] [Accepted: 04/19/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Severe infections are among the most common causes of death in immunocompromised patients admitted to the intensive care unit. The epidemiology, diagnosis and treatment of these infections has evolved in the last decade. AIMS We aim to provide a comprehensive review of these severe infections in this population. SOURCES Review of the literature pertaining to severe infections in critically ill solid organ transplant recipients. PubMed and Embase databases were searched for documents published since database inception until November 2017. CONTENT The epidemiology of severe infections has changed in the immunocompromised patients. This population is presenting to the intensive care unit with specific transplantation procedure-related infections, device-associated infections, a multitude of opportunistic viral infections, an increasing number of nosocomial infections and bacterial diseases with a more limited therapeutic armamentarium. Both molecular diagnostics and imaging techniques have had substantial progress in the last decade, which will, we hope, translate into faster and more precise diagnoses, as well as more optimal empirical treatment de-escalation. IMPLICATIONS The key clinical elements to improve the outcome of critically ill solid organ transplant recipients depend on the knowledge of geographic epidemiology, specific surgical procedures, net state of immunosuppression, hospital microbial ecology, aggressive diagnostic strategy and search for source control, rapid initiation of antimicrobials and minimization of iatrogenic immunosuppression.
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Abstract
In 2017, most intensive care units (ICUs) worldwide are admitting a growing population of immunosuppressed patients. The most common causes of pre-ICU immunosuppression are solid organ transplantation, hematopoietic stem cell transplantation, and infection due to human immunodeficiency virus. In this article, the authors review the most frequent infections that cause critical care illness in each of these 3 immunosuppressed patient populations.
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Affiliation(s)
- Diana F Florescu
- Transplant Infectious Diseases Program, Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA
| | - Uriel Sandkovsky
- Transplant Infectious Diseases Program, Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA
| | - Andre C Kalil
- Transplant Infectious Diseases Program, Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA.
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9
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Doulberis M, Panagopoulos P, Scherz S, Dellaporta E, Kouklakis G. Update on ischemic colitis: from etiopathology to treatment including patients of intensive care unit. Scand J Gastroenterol 2016; 51:893-902. [PMID: 27152750 DOI: 10.3109/00365521.2016.1162325] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Ischemic colitis is the result of colonic hypoperfusion and is regarded as a relatively rare condition. It can be roughly classified as occlusive and non-occlusive. Pathogenesis includes a usually transient compromise in the colonic vasculature, with a parallel activation of an inflammatory cascade caused primarily by reperfusion. Diagnosis of ischemic colitis remains often difficult and requires a combination of diagnostic techniques, whereas clinical signs are occasionally only seen late as complications. Gold standard is considered to be colonoscopy. Clinical presentation and treatment of ischemic colitis vary widely depending on the degree of ischemia. Patients of intensive care unit (ICU) with ischemic colitis are often under-diagnosed, since the parallel co-morbidities and the nonspecific nature of symptoms that mimic almost any abdominal pathology, can mislead the doctor. Moreover, sedated or ventilated patients can mask many of the characteristic features of ischemic colitis and make the diagnosis challenging. Bedside colonoscopy and diagnostic laparoscopy in ICUs are two options, which seem lately to be reliable and promising in diagnosing ischemic colitis in critically ill patients.
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Affiliation(s)
- Michael Doulberis
- a Department of Internal Medicine , Hospital of Solothurn , Solothurn , Switzerland
| | - Periklis Panagopoulos
- b Department of Internal Medicine , Democritus University of Thrace, University General Hospital of Alexandroupolis , Alexandroupolis , Greece
| | - Stephanie Scherz
- c Department of Surgery , Hospital of Burgdorf , Burgdorf , Switzerland
| | - Erminia Dellaporta
- d Gastrointestinal Endoscopy Unit , Democritus University of Thrace, University General Hospital of Alexandroupolis , Alexandroupolis , Greece
| | - Georgios Kouklakis
- d Gastrointestinal Endoscopy Unit , Democritus University of Thrace, University General Hospital of Alexandroupolis , Alexandroupolis , Greece
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Hasegawa T, Aomatsu K, Nakamura M, Aomatsu N, Aomatsu K. Cytomegalovirus colitis followed by ischemic colitis in a non-immunocompromised adult: A case report. World J Gastroenterol 2015; 21:3750-3754. [PMID: 25834346 PMCID: PMC4375603 DOI: 10.3748/wjg.v21.i12.3750] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 11/15/2014] [Accepted: 12/16/2014] [Indexed: 02/06/2023] Open
Abstract
We report a rare case of cytomegalovirus (CMV) colitis followed by severe ischemic colitis in a non-immunocompromised patient. An 86-year-old woman was admitted after experiencing episodes of vomiting and diarrhea. The next day, hematochezia was detected without abdominal pain. The initial diagnosis of ischemic colitis was based on colonoscopy and histological findings. The follow-up colonoscopy revealed a prolonged colitis. Immunohistochemical staining detected CMV-positive cells following conservative therapy. Intravenous ganciclovir therapy led to successful healing of ulcers and disappearance of CMV-positive cells. The prevalence of CMV infection is common in adults. CMV colitis is relatively common in immunocompromised patients; however, it is rare in immunocompetent patients. In our case, CMV infection was allowed to be established due to the disruption of the colonic mucosa by the prior severe ischemic colitis. Our experience suggests that biopsies may be necessary to detect CMV and the prompt management of CMV colitis should be instituted when intractable ischemic colitis is observed.
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Barba T, Pasquet F, Nibaud A, Maïs L, Hot A, Pavic M, Mahr A. [Prolonged fever in a 62-year-old man]. Rev Med Interne 2013; 35:206-9. [PMID: 24080237 DOI: 10.1016/j.revmed.2013.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 06/22/2013] [Indexed: 10/26/2022]
Affiliation(s)
- T Barba
- Service de médecine interne - oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France.
| | - F Pasquet
- Service de médecine interne - oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France
| | - A Nibaud
- Service de médecine interne - oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France
| | - L Maïs
- Service de médecine interne - oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France
| | - A Hot
- Service de médecine interne, hôpital Édouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France
| | - M Pavic
- Service de médecine interne - oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France
| | - A Mahr
- Service de médecine interne, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75475 Paris, France
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de Andrade LGM, Rodrigues MAM, Romeiro FG, Carvalho MFC. Gastrointestinal cytomegalovirus disease in renal transplant recipients: a case series. Clin Transplant 2011; 26:345-50. [PMID: 22017269 DOI: 10.1111/j.1399-0012.2011.01514.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The purpose of this article was to report a series of 23 renal transplant recipients with histologically proven and immunohistochemically confirmed cytomegalovirus (CMV) lesions in the gastrointestinal tract (GIT) and to assess the risk factors associated with severe disease/mortality. CMV patients (n=23) were allocated into two groups: those who died (n=6) and those considered cured (n=17). Overall mortality rate was 26% (6/23). Initial symptoms suggestive of lower GIT involvement were observed in all death cases and in 35.3% of those cured (p=0.01). Enterorrhagia was seen in 83.3% of the patients who died. Death risk increased twofold (RR 2 [1.13-3.52], p=0.01) when symptoms of lower GIT involvement were initially observed and sixfold when enterrohagia was present (RR 6 [1.1-35.9], p=0.001). Among death cases, mean time at diagnosis was significantly more distant (2002±2.9×2008±1.6, p=0.04). The difference in mortality rates seen as service practices changed along the years demonstrates the importance of early diagnosis.
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Kim CH, Bahng S, Kang KJ, Ku BH, Jo YC, Kim JY, Chang DK, Son HJ, Rhee PL, Kim JJ, Rhee JC, Kim YH. Cytomegalovirus colitis in patients without inflammatory bowel disease: a single center study. Scand J Gastroenterol 2010; 45:1295-301. [PMID: 20568970 DOI: 10.3109/00365521.2010.499962] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Cytomegalovirus (CMV) aggravates preexisting inflammatory bowel disease (IBD), and there are numerous reports of CMV colitis in IBD patients. However, little attention has been paid to CMV colitis in non-IBD patients. The aim was to determine the clinical manifestations, endoscopic appearance, and clinical course of CMV colitis in non-IBD patients. MATERIAL AND METHODS We reviewed medical records of patients diagnosed with CMV colitis based on immunohistochemical studies of biopsy specimens or surgical specimens between 1998 and 2009. RESULTS The medical records of 43 patients were reviewed. Subjects included individuals with AIDS, and those undergoing chemotherapy, steroid therapy, or transplantation, as well as individuals with other co-morbidities and individuals with no previous illnesses. Frequent symptoms were non-bloody diarrhea, abdominal pain, fever, and hematochezia. Macroscopically normal rectosigmoid mucosa was observed in eight of 21 patients who underwent full-length colonoscopy. Endoscopic findings were varied, and included macroscopically normal (n = 2), colitis alone (n = 12), ulcer alone (n = 5), and ulcer with colitis (n = 22). The ulcer margin was well-circumscribed in 12 of 21 patients. Thirty-six patients were administered antiviral agents and two patients died. All patients who were not treated with an antiviral agent recovered spontaneously while waiting for their biopsy results. CONCLUSIONS Colonoscopy is preferred to sigmoidoscopy for diagnosis of CMV colitis. Antiviral therapy should not be mandatory for a subset of patients with CMV colitis.
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Affiliation(s)
- Chi Hoon Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Babakir-Mina M, Ciccozzi M, Alteri C, Polchi P, Picardi A, Greco F, Lucarelli G, Arcese W, Perno CF, Ciotti M. Excretion of the novel polyomaviruses KI and WU in the stool of patients with hematological disorders. J Med Virol 2009; 81:1668-73. [PMID: 19626610 DOI: 10.1002/jmv.21559] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Infection with human polyomaviruses BKV and JCV is asymptomatic, and lifelong and widespread, among the general population. However, in the setting of immunosuppression, secondary to medications or viral infection, for example, with HIV, reactivation can occur and result in severe disease. In this study, stool specimens from 31 patients with hematological disorders (25 transplanted and 6 non-transplanted) were examined prospectively to determine whether the novel polyomaviruses KIV and WUV reactivated and were excreted in the gastrointestinal tract. Reactivation was correlated with the appearance of gastrointestinal and respiratory symptoms. Of the 31 patients examined, KIV and WUV were detected in 13 transplanted patients as single infection or in combination with BKV, cytomegalovirus (CMV), and adenovirus (Adv). Because of frequent co-infections, a clear correlation between novel polyomaviruses and clinical symptoms could not be established. There was no correlation between demographic variables and detection of KIV and WUV. Phylogenetic analysis of the small t-antigen gene of KIV and WUV isolates showed that the novel polyomaviruses identified in feces clustered with those identified in the respiratory tract suggesting an oral-fecal transmission of these viruses. The novel polyomaviruses KI and WU may have a pathogenic role in immunocompromised patients.
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Affiliation(s)
- Muhammed Babakir-Mina
- Laboratory of Molecular Virology, University Hospital Tor Vergata, Viale Oxford, Rome, Italy
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Abstract
Cytomegalovirus (CMV) is a cause of significant morbidity and mortality in solid organ transplant recipients. Gastrointestinal (GI) tract infection by CMV in this population can cause symptomatic disease, which typically manifests as fever, abdominal pain, nausea, and bloody diarrhea. Erosive lesions of the GI mucosa are often evident on endoscopic exam. We report an unusual presentation of CMV enteritis in a kidney and liver transplant recipient with the development of acute onset voluminous watery diarrhea in the absence of other typical symptoms and subsequent progression to hypovolemic shock and acute renal failure. This case emphasizes the atypical presentations of common opportunistic infections that may occur in immunosuppressed hosts.
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Affiliation(s)
- M Alhyraba
- Department of Internal Medicine, Section of Infectious Diseases, University of Illinois at Chicago, Chicago, Illinois 60612, USA
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Veroux M, Puzzo L, Corona D, Buffone A, Tallarita T, Murabito P, Veroux P. Cytomegalovirus and Clostridium difficile ischemic colitis in a renal transplant recipient: a lethal complication of anti-rejection therapy? Urol Int 2007; 79:177-9; discussion 180. [PMID: 17851290 DOI: 10.1159/000106334] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2006] [Accepted: 07/07/2006] [Indexed: 12/26/2022]
Abstract
Intestinal ischemia is reported to be the most common gastrointestinal complication of renal transplantation and a potential cause of morbidity and mortality. The recent use of more potent immunosuppressive drug regimens has reduced the incidence of acute rejection, increasing the incidence of potentially fatal infectious complications, such as clinically important cytomegalovirus (CMV) infection. A 42-year-old kidney transplant recipient experienced on postoperative day 10 a dehiscence of the ureterovesical anastomosis, associated with a 7-cm longitudinal tear graft on the lower pole of the kidney and an ureteral ischemia. A graft biopsy demonstrated a mild acute rejection for which the patient received an unsuccessful administration of steroids, with progression of the rejection, so that 1 mg/kg/day antithymocyte globulin was administered. Two days later the patient presented with fever (39.5 degrees C), diffuse abdominal pain with tenderness and bloody diarrhea, and diagnosis of CMV colitis was achieved; rectal samples were taken for histologic examination, and Clostridium difficile toxin was isolated. A subtotal colectomy with Hartmann's procedure was performed, but the patient died 13 days later of a multiple organ failure. The risk of lethal CMV colitis is increased in patients being treated with anti-rejection therapy for severe acute rejection; the occurrence of simultaneous infection, such as pseudomembranous colitis, usually characterized by a favorable prognosis, increases the mortality rate in these patients.
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Affiliation(s)
- Massimiliano Veroux
- Department of Surgery, Transplantation and Advanced Technologies, Organ Transplant Unit, University Hospital of Catania, Catania, Italy.
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Abstract
Gastrointestinal complications are common after kidney, liver, pancreas, heart, and lung transplantation. Complications can include gastrointestinal conditions preceding the transplantation, viral, fungal, and bacterial gastrointestinal infections, and gastrointestinal side effects of medications including immunosuppressive agents. Establishing the etiology of gastrointestinal complaints is often difficult because any one or a combination of these factors might be contributory in the same patient.
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Affiliation(s)
- Amitabh Gautam
- Brown Medical School, Division of Organ Transplantation, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA.
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19
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Abstract
An asymptomatic, but highly significant, rise in serum alkaline phosphatase (AP) levels developed in a renal transplant recipient. Investigations ruled out bony or hepatobiliary disease. Subsequent diarrhea and weight loss led to a diagnosis of cytomegalovirus (CMV) colitis, which was confirmed with a positive CMV pp65 antigenemia test and an endoscopic finding of multiple colonic erosions. Intravenous ganciclovir led to complete patient recovery and a swift reduction of serum AP levels to normal. Normally, intestinal AP isoenzymes are cleared quickly from the circulation. However, acute bowel diseases, especially when inflammatory in origin, can produce high serum AP levels. In this presented patient, the rise in serum AP levels preceded symptomatic manifestations of CMV colitis, and fell with successful therapy. Acute CMV disease in solid organ transplant recipients is common, can take many shapes, and needs to be diagnosed quickly. An unexplained rise in serum AP levels should lead to a search for inflammatory bowel disease, specifically CMV colitis, in transplanted patients.
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Affiliation(s)
- A Korzets
- Department of Nephrology and Hypertension, Rabin Medical Center-Campus Golda, Petach Tikva 14900, Israel
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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] [What about the content of this article? (0)] [Affiliation(s)] [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
Gastrointestinal complications are frequent in renal transplant recipients and can include oral lesions, esophagitis, peptic ulcer, diarrhea, colon disorders and malignancy. Oral lesions may be caused by drugs such as cyclosporine and sirolimus, by virus or fungal infections. Leukoplakia may develop in patients with Epstein-Barr virus (EBV) infection. The commonest esophageal disorder is represented by fungal esophagitis usually caused by candida. A number of patients may suffer from nausea, vomiting and gastric discomfort. These disorders are more frequent in patients treated with mycophenolate mofetil (MMF). Peptic ulcer is more rare than in the past. Patients with a history of peptic ulcer are particularly prone to this complication. Other gastroduodenal disorders are caused by cytomegalovirus (CMV) and herpes simplex infection. Diarrhea is a frequent disorder which may be caused by pathogen microorganisms or by immunosuppressive agents. The differential diagnosis may be difficult. Colon disorders mainly consist of hemorrhage, usually sustained by CMV infection, or perforation which may be caused by diverticulitis or intestinal ischemia. Colon cancer, anal carcinoma, and EBV-associated lymphoproliferative disorders are particularly frequent in transplant recipients. A particular gastric lymphoma called mucosa-associated lymphoid tissue (MALT) lymphoma may develop in renal transplant patients. It usually responds to the eradication of Helicobacter pylori.
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Affiliation(s)
- Claudio Ponticelli
- Clinical Immunology Unit, IRCCS Istituto Auxologico Italiano, Milano, Italy.
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