A 50-year-old man comes to the physician with complaints of low-grade fever, malaise, and intermittent diarrhea. He experiences a burning sensation in his chest when he swallows food. He received a living related-donor kidney transplant 5 months ago. The donor and recipient were both cytomegalovirus immunoglobulin G antibody positive and Epstein-Barr virus antibody positive. Valganciclovir prophylaxis was given for 100 days. The patient experienced an acute cellular rejection 3 weeks ago that was diagnosed after kidney biopsy. He was treated with pulse methylprednisolone and a change from cyclosporine to tacrolimus. His rejection was successfully treated and his kidney function stabilized.
On examination, the patient is in no distress. His temperature is 38.1 C (100.5 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 16/min. Pulse oximetry is 97% on room air. Ocular fundi show no exudates or papilledema. The remainder of his physical examination is within normal limits.
Laboratory results are as follows:

A chest x-ray is normal and unchanged from a pre-transplant film.
Which of the following is the most likely explanation for this patient's illness?

Question

A 50-year-old man comes to the physician with complaints of low-grade fever, malaise, and intermittent diarrhea.  He experiences a burning sensation in his chest when he swallows food.  He received a living related-donor kidney transplant 5 months ago.  The donor and recipient were both cytomegalovirus immunoglobulin G antibody positive and Epstein-Barr virus antibody positive.  Valganciclovir prophylaxis was given for 100 days.  The patient experienced an acute cellular rejection 3 weeks ago that was diagnosed after kidney biopsy.  He was treated with pulse methylprednisolone and a change from cyclosporine to tacrolimus.  His rejection was successfully treated and his kidney function stabilized.
On examination, the patient is in no distress.  His temperature is 38.1 C (100.5 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 16/min.  Pulse oximetry is 97% on room air.  Ocular fundi show no exudates or papilledema.  The remainder of his physical examination is within normal limits.
Laboratory results are as follows:

A chest x-ray is normal and unchanged from a pre-transplant film.
Which of the following is the most likely explanation for this patient's illness?

Quizplus · Accepted Answer

11ec193a_9858_da40_853d_77b0e91a37ba_MD0002_00 This patient most likely has cytomegalovirus (CMV) disease. CMV infection is defined as detection of CMV antibodies, antigen, DNA, or virus without significant clinical symptoms. CMV disease is usually associated with a rejection episode and increased immunosuppression. Patients typically develop a mononucleosis-like illness with low-grade fever, malaise, leukopenia, and some degree of organ involvement (eg, hepatitis, pancreatitis, colitis, meningoencephalitis, and pneumonitis). CMV eye disease is more common in HIV than organ transplant patients. CMV disease is more common in CMV-positive donors and CMV-positive recipients. Several strains of cytomegalovirus do not confer cross-immunity. Recipients may have reactivation of existing virus or superinfection with a new donor viral strain. This patient was appropriately treated with valgancicyclovir (preferred prophylactic for CMV) for the first 3 months following transplantation but had organ rejection with a change in immunosuppression. Treatment usually involves immunosuppression reduction and antiviral therapy (eg, ganciclovir) for more severe disease. However, cyclosporine or tacrolimus is not discontinued unless there is life-threatening disease. (Choice A) BK viral infection occurs in about 5% of renal transplant recipients and usually presents with tubulointerstitial nephritis and occasional ureteric stenosis. Most centers monitor patients with periodic BK-PCR or acute organ dysfunction up to a few years post transplantation. Kidney biopsy usually shows the characteristic findings for BK involvement, which were not seen in this patient. (Choice C) Herpes simplex reactivation commonly occurs in the first months after solid organ transplantation and may present with oral/genital lesions, esophagitis, pneumonitis, hepatitis, and encephalitis. This patient's illness is not typical for herpes simplex infection. (Choice D) Tacrolimus toxicity usually presents with acute nephrotoxicity, hypertension, neurotoxicity (eg, tremor), and metabolic disturbances (eg, glucose intolerance). This patient's absence of hypertension and nephrotoxicity makes this less likely. (Choice E) Toxoplasma gondii infection rarely occurs following renal transplantation and presents with lymphadenopathy, hepatosplenomegaly, pneumonitis, myocarditis, brain abscess, and chorioretinitis. Absence of these findings in this patient makes Toxoplasma infection less likely. Educational objective: Cytomegalovirus (CMV) disease commonly occurs in the first few months after solid organ transplantation. Infection is defined as CMV viral isolation, and disease is defined as clinical symptoms (eg, mononucleosis-like syndrome) with organ involvement (eg, hepatitis, colitis, and pneumonitis). Treatment involves immunosuppression reduction and antiviral therapy (eg, ganciclovir) for more severe disease. __________ References: Viral infection in the renal transplant recipient. (http://www.ncbi.nlm.nih.gov/pubmed/15829710) International consensus guidelines on the management of cytomegalovirus in solid organ transplantation. (http://www.ncbi.nlm.nih.gov/pubmed/20224515)

A 50-Year-Old Man Comes to the Physician with Complaints of Low-Grade