Complicated gastrointestinal CMV disease after small bowel transplantation

We report a case of a 52 year old small bowel transplant recipient, with a clinical course complicated by CMV disease. Recipient and donor were CMV-IgG positive. Ganciclovir i.v., followed by valganciclovir was used for CMV-prophylaxis for 100 days. An antilymphocytic induction therapy was performed with Alemtuzumab on days 0 and 1. Immunosuppression was continued with tacrolimus, mycophenolat mofetil, prednisolon. Six months posttransplant the patient presented with CMV tissue invasive disease of the esophagus and stomach, without presence of viremia, tested by quantitative PCR. Treatment with ganciclovir resulted in complete viral load suppression and valganciclovir was initiated for secondary prophylaxis, whereas mycophenolat mofetil and prednisolon were discontinued. Shortly afterwards candida and recurrent CMV based esophagitis was diagnosed, still without viremia. Improvement was achieved with ganciclovir and caspofungin. However, during the following course the patient developed CMV tissue invasive disease of the ileal graft, with persistent absence of viremia. Antiviral coverage was extended with foscarnet and CMV immunoglobulin. Viral load declined to undetectable levels, however the patient failed to improve clinically due to occurrence of graft rejection. Despite infliximab and high dose prednisolon, graft rejection was progressive, requiring surgical explantation of the graft. This case highlights the importance of additional diagnostic tools such as endoscopy including PCR analysis of tissue samples. Extension of primary antiviral prophylaxis interval up to 6 months and prolonged retreatment in recurrent CMV disease may be useful to avoid severe CMV-related complications.