Colon perforation due to antigenemia-negative cytomegalovirus gastroenteritis after liver transplantation: A case report and review of literature

BACKGROUND Cytomegalovirus(CMV) remains a critical complication after solid-organ transplantation. The CMV antigenemia(AG) test is useful for monitoring CMV infection. Although the AG-positivity rate in CMV gastroenteritis is known to be low at onset, almost all cases become positive during the disease course. We treated a patient with transverse colon perforation due to AG-negative CMV gastroenteritis, following a living donor liver transplantation(LDLT).CASE SUMMARY The patient was a 52-year-old woman with decompensated liver cirrhosis as a result of autoimmune hepatitis who underwent a blood-type compatible LDLT with her second son as the donor. On day 20 after surgery, upper and lower gastrointestinal endoscopy(GE) revealed multiple gastric ulcers and transverse colon ulcers. The biopsy tissue immunostaining confirmed a diagnosis of CMV gastroenteritis. On day 28 after surgery, an abdominal computed tomography revealed transverse colon perforation, and simple lavage and drainage were performed along with an urgent ileostomy. Although the repeated remission and aggravation of CMV gastroenteritis and acute cellular rejection made the control of immunosuppression difficult, the upper GE eventually revealed an improvement in the gastric ulcers, and the biopsy samples were negative for CMV. The CMV-AG test remained negative, therefore, we had to evaluate the status of the CMV infection on the basis of the clinical symptoms and GE.CONCLUSION This case report suggests a monitoring method that could be useful for AGnegative CMV gastroenteritis after a solid-organ transplantation.

Maintenance treatment with infliximab for ulcerative ileitis after intestinal transplantation: A case report

BACKGROUND Evidence has been published on the successful applications of the anti-tumor necrosis factor alpha antibody infliximab,such as induction therapy,salvage treatment for acute cellular rejection,and treatment for chronic ulcerative inflammation,in intestinal transplant recipients.However,the optimal protocol for the effective use of infliximab remains largely undetermined due to scarcity of available clinical data.We report a continuative application of infliximab as maintenance therapy for recurrent chronic ulcerative ileitis in a recipient of isolated intestinal transplantation(ITx).CASE SUMMARY The patient was a 11-year-old boy with intestinal motility disorder classified as a hypogenic type of intestinal dysganglionosis.The patient underwent living-donor related intestinal transplant.His immunosuppression regimen consisted of daclizumab,tacrolimus,and steroids.Although he did not show rejection while on tacrolimus monotherapy,routine screening endoscopy showed several ulcerative lesions in the distal end of the graft 2 years after the intestinal transplant.Endoscopic work up to evaluate the progression of anemia revealed stenosis with ulcerative inflammatory changes and multiple longitudinal ulcers in the graft.Since the endoscopic findings suggested ulcerative lesions in Crohn’s disease,infliximab treatment was considered.Treatment with infliximab and a small dose of oral prednisolone afforded successful withdrawal of total parenteral nutrition and maintenance of a well-functioning graft without infectious complications for 5 years since the administration of the first dose of infliximab.CONCLUSION Infliximab is effective as maintenance therapy for recurrent chronic ulcerative ileitis in an isolated ITx patient.