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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 1  |  Page : 133-134
A successful renal transplant after cytomegalovirus colitis in a dialysis patient


1 Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication3-Jan-2012
 

How to cite this article:
Ignatius A, Gupta A, Jain SB, Agarwal SK, Kalson NK. A successful renal transplant after cytomegalovirus colitis in a dialysis patient. Saudi J Kidney Dis Transpl 2012;23:133-4

How to cite this URL:
Ignatius A, Gupta A, Jain SB, Agarwal SK, Kalson NK. A successful renal transplant after cytomegalovirus colitis in a dialysis patient. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2019 Oct 18];23:133-4. Available from: http://www.sjkdt.org/text.asp?2012/23/1/133/91319
To the Editor,

Cytomegalovirus (CMV) is well known to cause gastrointestinal complications in immuno-compromised states like those in allograft recipients and human immunodeficiency virus (HIV)-infected individuals. Dialysis patients are also prone to CMV infection, but primary involvement of colon is rare. We present a case of cytomegalovirus colitis in a young gentleman on hemodialysis who also had associated hepatitis C infection. After treatment of CMV disease, he underwent a successful renal transplant under cover of valgancyclovir prophylaxis. There was no recurrence of the disease and he had good graft functions one year post-transplant.

A 20-year-old man with chronic kidney disease on hemodialysis awaiting renal transplant and who had acquired hepatitis C infection four months back presented with bloody diarrhea and fever for three days. On examination, he was febrile and had pulse 88/min and blood pressure 166/96 mmHg. Chest, cardiovascular and neurological examinations were normal. Abdomen was diffusely tender, but no mass was felt. Investigations showed hemoglobin 8.1 g/dL, leukocyte count 500/mm³ -60% neutrophils, platelet 40,000/mm³, reticulocyte count 1% and microcytic hypochromic picture. Biochemistry showed fasting plasma glucose 88 mg/dL, bilirubin 0.9 mg/dL and alanine/aspartate aminotransferase 170/134 U/L. Hepatitis B surface antigen and HIV were negative. Stool for ova/cyst and culture was negative. Ultrasound abdomen revealed mild hepatomegaly and ascites. The patient was given intravenous Levofloxacin 250 mg EOD and Piperacillin/Tazobactum 2.25 g TID. He did not improve, and flexible sigmoidoscopy was performed. It showed patchy erythema in rectum and sigmoid. Rectal biopsy revealed ulcerated mucosa and inclusion bodies suggestive of CMV [Figure 1]. CMV polymerase chain reaction (PCR) was positive and intravenous (i.v.) Gancyclovir 1.25 mg/kg/d was started, to which the patient responded. After 3 weeks of gancyclovir, he was put on valgancyclovir prophylaxis. Subsequently, CMV PCR done thrice were all negative.
Figure 1: Photomicrograph of rectal biopsy showing capillary endothelial cell (×40) with inclusion bodies (hematoxylin-eosin stain).

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He underwent renal transplant four months later, the mother being the donor, and was given cyclosporine, mycophenolate sodium and prednisolone. No induction agent was used. Valgancyclovir prophylaxis was continued for six months post-transplant. His graft functions remained normal and there were no features of CMV disease thereafter. Post transplant, one year period he is still uneventful and has stable graft functions.

Dialysis patients are prone to CMV infection; however, primary involvement of the colon is rare. [1],[2],[3],[4] Gastro-intestinal tract involvement may present as gastroenteritis, duodenitis, ileitis, colitis, proctitis or hepatitis. Complications of CMV colitis may be severe. Perforation may lead to peritonitis; toxic megacolon, fistulae, strictures may occur and severe diarrhea may cause malnourishment. CMV should be kept as a differential diagnosis of acute colitis in such cases. [5],[6]

Our case also highlights that CMV infection during the dialysis period is not a contraindication for transplant, of course, after proper treatment. Indeed, our patient did very well post-transplant without any evidence of disease recurrence, perhaps because of prophylaxis. We feel that such patients should not be given induction therapy, especially the much-used anti-thymocyte globulin. This would increase the risk of CMV recurrence.

Renal transplant physicians should be aware of this deadly infection in a dialysis patient and its careful post-transplant management. Unless a high index of suspicion for CMV is kept, differential case of acute colitis is likely to be missed. Early histological confirmation and prompt treatment helps to reduce morbidity and mortality.

 
   References Top

1.Tavernier G, Fernández M, Teruel JL, Redondo C, Echarri R, Ortuuño J. Colitis due to cytomegalovirus in a dialysis patient. Nefrologia 2004;24:279-82.  Back to cited text no. 1
    
2.Falagas ME, Griffiths J, Prekezes J, Worthington M. Cytomegalovirus colitis mimicking colon carcinoma in an HIV-negative patient with chronic renal failure. Am J Gastroenterol 1996;91:168-9.  Back to cited text no. 2
[PUBMED]    
3.Esforzado N, Poch E, Almirall J, Bombí JA, López-Pedret J, Revert L. Cytomegalovirus colitis in chronic renal failure. Clin Nephrol 1993;39:275-8.  Back to cited text no. 3
    
4.Rankin A, Cuthill K, Subesinghe M, Goldsmith D. Life-threatening rectal bleeding due to cytomegalovirus colitis in a haemodialysis patient. NDT Plus 2009;2:239-41.  Back to cited text no. 4
    
5.Rafailidis PI, Mourtzoukou EG, Varbobitis IC, Falagas ME. Severe cytomegalovirus infection in apparently immunocompetent patients: A systematic review. Virol J 2008;5:47.  Back to cited text no. 5
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6.Ng FH, Chau TN, Cheung TC, et al. Cytomegalovirus colitis in individuals without apparent cause of immunodeficiency. Dig Dis Sci 1999;44:945-52.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Ankur Gupta
Department of Nephrology, All India Institute of Medical Sciences, New Delhi
India
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PMID: 22237236

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