A 52-year-old man is evaluated for low-grade fever, malaise, abdominal pain, and diarrhea. The patient underwent a cadaveric renal transplant 6 months ago to treat renal failure from underlying polycystic kidney disease. He takes maintenance immunosuppressive therapy. Physical examination shows mild tenderness in the lower abdominal quadrants with no rebound tenderness. Serum immunosuppressant levels are within therapeutic range, and renal function studies are normal. Colonoscopy reveals mucosal erythema and ulcerations. Biopsy shows large cells with inclusion bodies, and a polymerase chain reaction-based test detects viral DNA. First-line therapy for the infection is initiated. This patient is at greatest risk of which of the following from the treatment?

Question

A 52-year-old man is evaluated for low-grade fever, malaise, abdominal pain, and diarrhea.  The patient underwent a cadaveric renal transplant 6 months ago to treat renal failure from underlying polycystic kidney disease.  He takes maintenance immunosuppressive therapy.  Physical examination shows mild tenderness in the lower abdominal quadrants with no rebound tenderness.  Serum immunosuppressant levels are within therapeutic range, and renal function studies are normal.  Colonoscopy reveals mucosal erythema and ulcerations.  Biopsy shows large cells with inclusion bodies, and a polymerase chain reaction-based test detects viral DNA.  First-line therapy for the infection is initiated.  This patient is at greatest risk of which of the following from the treatment?

Quizplus · Accepted Answer

Patients who undergo organ transplantation and are on immunosuppressive therapy are at risk for cytomegalovirus (CMV) reactivation with end-organ disease (eg, colitis, retinitis, pneumonitis). This patient has classic manifestations of CMV colitis including fever, fatigue, abdominal pain, and diarrhea. Because serum testing for CMV DNA may be negative, patients with suspected CMV colitis usually undergo colonoscopy with biopsy. Typical findings include colonic mucosal erythema/ulcerations. Biopsy generally reveals large cells with intranuclear and intracytoplasmic inclusions ("owl's-eye" appearance). First-line therapy for CMV colitis is intravenous ganciclovir. This guanine nucleoside analogue interferes with viral DNA replication by competitively inhibiting the incorporation of guanosine triphosphate into CMV DNA strands by CMV DNA polymerase. However, this drug also impedes human DNA polymerase to a lesser degree and can interfere with host cell replication, particularly in areas of high turnover (eg, hematologic progenitor cells). Therefore, ganciclovir is often associated with prominent hematologic side effects such as neutropenia, anemia, and thrombocytopenia. (Choice A) The tuberculosis medications isoniazid and pyrazinamide can cause significant hepatotoxicity. (Choice B) Myopathy and rhabdomyolysis can be associated with the use of integrase inhibitors (eg, raltegravir, dolutegravir) in the treatment of HIV. (Choice D) Pancreatitis is an important side effect of the HIV medication didanosine, a nucleoside reverse transcriptase inhibitor. (Choice E) Amiodarone is an antiarrhythmic medication that can cause hypothyroidism, hyperthyroidism, or thyroiditis. Educational objective: First-line therapy for CMV colitis and retinitis is ganciclovir. This medication inhibits viral synthesis by blocking CMV DNA polymerase. However, ganciclovir also blocks host DNA polymerase to a lesser degree, which can lead to hematologic side effects such as neutropenia, anemia, and thrombocytopenia.

A 52-Year-Old Man Is Evaluated for Low-Grade Fever, Malaise, Abdominal