CMV enteritis as unusual source of bleeding to GIT

2021 ◽  
Vol 75 (4) ◽  
pp. 304-310
Author(s):  
David Varyš ◽  
Janka Slatinská ◽  
Veronika Pítová ◽  
Klára Chmelová ◽  
Julius Špičák ◽  
...  
Keyword(s):  
Severe Disease ◽  
Organ Transplant ◽  
Therapeutic Endoscopy ◽  
Experimental Medicine ◽  
Intestinal Bleeding ◽  
Severe Bleeding ◽  
Solid Organ ◽  
Selective Embolization ◽  
Intravenous Ganciclovir ◽  
Acute Dyspnoea

Introduction: Cytomegalovirus disease affecting the gastrointestinal tract is a rare but severe disease presenting particularly in people under immunosuppression, solid organ transplant recipients and AIDS patients with CD4 count under 100/mm3. When colon or small intestine are affected, the disease may be complicated by severe bleeding. CMV therapy includes antivirals and, in case of bleeding, methods of therapeutic endoscopy or interventional radiology. Case description: We present a case of a 74-year-old woman 3 years after kidney transplantation owing to vascular nephrosclerosis, treated with belatacept, mycophenolate mophetile and prednisone. She was admitted to hospital for acute dyspnoea. During hospitalisation, she presented with intestinal bleeding, but the endoscopic intervention at the first colonoscopy was not successful. She was referred to the Department of Hepatogastroenterology of the Institute of Clinical and Experimental Medicine and subsequent colonoscopy revealed a 15 cm long part of ileum with ulcerations as the source of bleeding. The histological assessment described a severe CMV enteritis. The CMV DNA blood level established by PCR was higher than 10 000 000 U/ml. The patient was treated with intravenous ganciclovir and she underwent selective embolization of the inferior mesenteric artery with an excellent clinical effect. Conclusions: CMV enteritis may be associated with a high mortality. The approach to therapy is multidisciplinary and needs collaboration of gastroenterologist, endoscopist and interventional radiologist. Key words: CMV – GIT bleeding – immunosuppression – transplantation

Valganciclovir Dosing for Cytomegalovirus Prophylaxis in Solid-organ Transplant Recipients on Continuous Veno-venous Hemodialysis

2020 ◽  
Author(s):  
Andrew S Jarrell ◽  
Jessica R Crow ◽  
Sara E Strout ◽  
Rachel M Kruer ◽  
Lindsey P Toman ◽  
...  
Keyword(s):  
Organ Transplant ◽  
Population Based ◽  
Solid Organ Transplant ◽  
Solid Organ ◽  
Open Label ◽  
Intravenous Ganciclovir ◽  
Trough Concentrations ◽  
Average Body Mass ◽  
Bilateral Lung ◽  
Cmv Prophylaxis

Abstract Background Optimal valganciclovir dosing for cytomegalovirus (CMV) prophylaxis in solid-organ transplant (SOT) patients on continuous veno-venous hemodialysis (CVVHD) is not known. Ganciclovir trough concentrations ≥0.60 μg/mL have been suggested for CMV prophylaxis. This study was conducted to determine if valganciclovir 450 mg enterally every 24 hours achieves ganciclovir trough concentrations ≥0.60 μg/mL in patients on CVVHD. Methods This single-center, prospective, open-label, pharmacokinetic study included adult SOT patients admitted to an intensive care unit from March 2018 to June 2019 on CVVHD. All patients were receiving valganciclovir 450 mg enterally every 24 hours for CMV prophylaxis prior to enrollment. Each patient had a peak and trough sample drawn at steady state. Results Ten SOT patients were included in the study (6 liver, 1 simultaneous liver-kidney, 2 bilateral lung, 1 heart). The mean ± SD age was 51.8 ± 14.0 years, and average body mass index was 27 ± 6.9 kg/m2. Ganciclovir trough concentrations ranged from 0.31 to 3.16 μg/mL, and 80% of participants have trough concentrations ≥0.60 μg/mL. No patients had documented neutropenia while on valganciclovir and CVVHD; 60% of patients had significant thrombocytopenia. Conclusions Valganciclovir 450 mg enterally every 24 hours achieved ganciclovir trough concentrations ≥0.60 μg/mL in most patients on CVVHD, similar to those reported with intravenous ganciclovir for prophylaxis in this population. Based on these data, valganciclovir may require dosing every 24 hours to achieve concentrations equivalent to ganciclovir. Neutropenia did not occur in the study period. Thrombocytopenia was common and likely multifactorial.

DOSING OF INTRAVENOUS GANCICLOVIR FOR THE PROPHYLAXIS AND TREATMENT OF CYTOMEGALOVIRUS INFECTION IN SOLID ORGAN TRANSPLANT RECIPIENTS1

2000 ◽  
Vol 69 (3) ◽  
pp. 389-394 ◽  
Author(s):  
Jay A. Fishman ◽  
Maureen T. Doran ◽  
Sheila A. Volpicelli ◽  
A. Benedict Cosimi ◽  
James G. Flood ◽  
...  
Keyword(s):  
Cytomegalovirus Infection ◽  
Organ Transplant ◽  
Solid Organ Transplant ◽  
Solid Organ ◽  
Intravenous Ganciclovir

scholarly journals Coronavirus Disease 2019 in Solid Organ Transplant: A Multicenter Cohort Study

2020 ◽  
Author(s):  
Olivia S Kates ◽  
Brandy M Haydel ◽  
Sander S Florman ◽  
Meenakshi M Rana ◽  
Zohra S Chaudhry ◽  
...  
Keyword(s):  
Cohort Study ◽  
Severe Disease ◽  
Organ Transplant ◽  
Solid Organ Transplant ◽  
Solid Organ ◽  
Chest Imaging ◽  
Multicenter Cohort Study ◽  
Multicenter Cohort ◽  
Abnormal Chest

Abstract Background The coronavirus disease 2019 (COVID-19) pandemic has led to significant reductions in transplantation, motivated in part by concerns of disproportionately more severe disease among solid organ transplant (SOT) recipients. However, clinical features, outcomes, and predictors of mortality in SOT recipients are not well described. Methods We performed a multicenter cohort study of SOT recipients with laboratory-confirmed COVID-19. Data were collected using standardized intake and 28-day follow-up electronic case report forms. Multivariable logistic regression was used to identify risk factors for the primary endpoint, 28-day mortality, among hospitalized patients. Results Four hundred eighty-two SOT recipients from >50 transplant centers were included: 318 (66%) kidney or kidney/pancreas, 73 (15.1%) liver, 57 (11.8%) heart, and 30 (6.2%) lung. Median age was 58 (interquartile range [IQR] 46–57), median time post-transplant was 5 years (IQR 2–10), 61% were male, and 92% had ≥1 underlying comorbidity. Among those hospitalized (376 [78%]), 117 (31%) required mechanical ventilation, and 77 (20.5%) died by 28 days after diagnosis. Specific underlying comorbidities (age >65 [adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 1.7–5.5, P < .001], congestive heart failure [aOR 3.2, 95% CI 1.4–7.0, P = .004], chronic lung disease [aOR 2.5, 95% CI 1.2–5.2, P = .018], obesity [aOR 1.9, 95% CI 1.0–3.4, P = .039]) and presenting findings (lymphopenia [aOR 1.9, 95% CI 1.1–3.5, P = .033], abnormal chest imaging [aOR 2.9, 95% CI 1.1–7.5, P = .027]) were independently associated with mortality. Multiple measures of immunosuppression intensity were not associated with mortality. Conclusions Mortality among SOT recipients hospitalized for COVID-19 was 20.5%. Age and underlying comorbidities rather than immunosuppression intensity-related measures were major drivers of mortality.

scholarly journals COVID-19 in immunocompromised populations: implications for prognosis and repurposing of immunotherapies

2021 ◽  
Vol 9 (6) ◽  
pp. e002630
Author(s):  
Jason D Goldman ◽  
Philip C Robinson ◽  
Thomas S Uldrick ◽  
Per Ljungman
Keyword(s):  
General Population ◽  
Respiratory Infections ◽  
Severe Disease ◽  
Organ Transplant ◽  
Immune Dysregulation ◽  
Solid Organ ◽  
Cell Transplant ◽  
Hematopoietic Stem ◽  
Persons Living With Hiv ◽  
Rheumatological Diseases

SARS-CoV-2 is the virus responsible for the COVID-19 pandemic. COVID-19 has highly variable disease severity and a bimodal course characterized by acute respiratory viral infection followed by hyperinflammation in a subset of patients with severe disease. This immune dysregulation is characterized by lymphocytopenia, elevated levels of plasma cytokines and proliferative and exhausted T cells, among other dysfunctional cell types. Immunocompromised persons often fare worse in the context of acute respiratory infections, but preliminary data suggest this may not hold true for COVID-19. In this review, we explore the effect of SARS-CoV-2 infection on mortality in four populations with distinct forms of immunocompromise: (1) persons with hematological malignancies (HM) and hematopoietic stem cell transplant (HCT) recipients; (2) solid organ transplant recipients (SOTRs); (3) persons with rheumatological diseases; and (4) persons living with HIV (PLWH). For each population, key immunological defects are described and how these relate to the immune dysregulation in COVID-19. Next, outcomes including mortality after SARS-CoV-2 infection are described for each population, giving comparisons to the general population of age-matched and comorbidity-matched controls. In these four populations, iatrogenic or disease-related immunosuppression is not clearly associated with poor prognosis in HM, HCT, SOTR, rheumatological diseases, or HIV. However, certain individual immunosuppressants or disease states may be associated with harmful or beneficial effects, including harm from severe CD4 lymphocytopenia in PLWH and possible benefit to the calcineurin inhibitor ciclosporin in SOTRs, or tumor necrosis factor-α inhibitors in persons with rheumatic diseases. Lastly, insights gained from clinical and translational studies are explored as to the relevance for repurposing of immunosuppressive host-directed therapies for the treatment of hyperinflammation in COVID-19 in the general population.

scholarly journals COVID-19 in Immunocompromised Hosts: What We Know So Far

2020 ◽  
Author(s):  
Monica Fung ◽  
Jennifer M Babik
Keyword(s):  
Inflammatory Responses ◽  
Severe Disease ◽  
Organ Transplant ◽  
Solid Organ Transplant ◽  
Current Evidence ◽  
Solid Organ ◽  
Transplant Recipients ◽  
Organ Transplant Recipients ◽  
Increased Risk ◽  
Solid Organ Transplant Recipients

Abstract The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused significant morbidity and mortality for patients and stressed healthcare systems worldwide. The clinical features and outcomes of COVID-19 among immunosuppressed patients, who are at presumed risk of more severe disease but who may also have decreased detrimental inflammatory responses, are not well characterized. We review the existing literature on COVID-19 among immunocompromised populations ranging from patients with cancer and solid-organ transplant recipients to patients with HIV and those receiving immunomodulatory therapy for autoimmune disease. Patients with malignancy and solid-organ transplant recipients may be at increased risk of severe COVID-19 disease and death, whereas for those with other types of immunocompromise, current evidence is less clear. Overall, further prospective controlled studies are needed to determine the attributable risk of immunocompromising conditions and therapies on COVID-19 disease prognosis.

scholarly journals 540. Prolonged Viral Shedding of SARS-CoV-2 In Solid Organ Transplant Recipients

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S337-S337
Author(s):  
Hannah Nam ◽  
Scott C Roberts ◽  
Sajal D Tanna ◽  
Michael G Ison
Keyword(s):  
Median Duration ◽  
Severe Disease ◽  
Organ Transplant ◽  
Solid Organ Transplant ◽  
Solid Organ ◽  
Transplant Recipients ◽  
Kidney Transplant Recipients ◽  
Viral Kinetics ◽  
Viral Shedding ◽  
Number Of Patients

Abstract Background Solid organ transplant (SOT) recipients are more susceptible to viral infection and present with differing viral kinetics when compared to non-immunocompromised cohorts. The duration of viral shedding in SOT recipients with SARS-CoV-2 infection is unknown. Methods All SOT recipients with a diagnosed of SARS-CoV-2 by nasopharyngeal of bronchoalveolar lavage RT-qPCR from March 06, 2020 to May 31, 2020 were identified. Viral shedding duration was obtained by evaluating all subsequent SARS-CoV-2 PCR results following initial positivity over time. Severity classification was defined as mild (outpatient), moderate (hospitalized), and severe (ICU level care). Data were obtained from electronic medical record case review and analyzed with Stata 16. Results 71 patients with a positive SARS-CoV-2 PCR test were identified. 50 (70.4%) were classified as mild/moderate disease, while 21 (29.5%) had severe disease. Median age was 56.5 (IQR 45 – 61.3) years, and 56.9% (n = 41) were male. Older age was significantly associated with severe disease. A disproportionate number of patients were African American/Black or Hispanic at 72.2% (n=52). Interestingly, Caucasian race was significantly associated with less severe outcomes (p=0.038). The majority of patients were kidney transplant recipients (46, 63.9%), followed by liver (13, 18.1%), heart (6, 8.3%), lung (3, 4.2%), and pancreas (9, 12.5%) with a median duration from transplantation at 5 (IQR 3 – 17) years. Overall mortality was 5.6% (n=4), with all deaths occurring only in those with severe disease (19.1%, n=4). Prolonged viral shedding was observed in few patients, with median duration of SARS-CoV-2 PCR positivity at 32 (IQR 18.5 – 41.0) days. One kidney recipient was observed with up to 64 days of positive SARS-CoV-2 RT-PCR from initial diagnosis despite not developing severe disease. Demographics and Outcomes Duration of Viral Shedding in SOT Patients with COVID-19 Conclusion COVID-19 can lead to significant outcomes in SOT with increased mortality in those with severe disease, as well as prolonged viral shedding. Further studies are needed to elucidate the full duration of viral shedding in this population. Disclosures Michael G. Ison, MD MS, AlloVir (Consultant)

scholarly journals 931. Epidemiology and Clinical Outcomes of SARS-CoV-2 Infection Among Pediatric Solid Organ Transplant Recipients: A Single-Center Case Experience

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S558-S558
Author(s):  
Jesus Sotelo ◽  
Esra Akkoyun ◽  
Giselle S Chery ◽  
Amal Aqul ◽  
Dev M Desai ◽  
...  
Keyword(s):  
Severe Disease ◽  
Univariate Analysis ◽  
Organ Transplant ◽  
Solid Organ Transplant ◽  
Positive Pressure ◽  
Solid Organ ◽  
Moderate Disease ◽  
Increased Risk ◽  
Gi Symptoms ◽  
The Impact

Abstract Background The impact of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection among pediatric solid organ transplant (SOT) recipients remains unclear. We sought to characterize the clinical epidemiology and outcomes following SARS-CoV-2 infection among pediatric SOT recipients in Dallas, TX. Methods Retrospective review of all SOT recipients with laboratory confirmed COVID-19 infection from March 1, 2020 –March 31, 2021. Demographic, clinical, and outcome data were stratified by transplant type and disease severity. Fischer’s exact test and Kruskall-Wallis test were used to evaluate risk factors for more severe disease among hospitalized children. Results Twenty-six SOT recipients with a median age of 14 years were included in the study. Fifteen (58%) were female, eighteen (69%) were Hispanic and thirteen (50%) were overweight/obese. Median time post-transplant was 3.6 years (1311 days, interquartile range (IQR) 394-2881). Fourteen patients were liver recipients, seven kidney, three heart, and two multiorgan. The majority of patients (65%) had a known community exposure and presented with fever (50%), cough (38%) and GI symptoms (19%). Half of all cases were hospitalized (n=13), with 2 requiring intensive care unit (ICU) admission, but no patients required positive pressure ventilation. Median hospital stay was 3 days. Five of the thirteen hospitalized patients were categorized as having moderate disease. No patients developed severe disease and there were no deaths. Older children, as well as children with multiple co-morbidities were noted on univariate analysis to be at higher risk for moderate, as compared to mild, disease. Conclusion SARS-CoV-2 infection among pediatric SOT recipients are at increased risk for hospital admission but demonstrate an overall mild /moderate disease course. Larger studies are required to elucidate the risk of morbidity between pediatric SOT recipients and immunocompetent children with SARS-CoV-2. Disclosures Amal Aqul, MD, Albireo pharma Inc. (Consultant)

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