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107 A CASE OF EARLY CMV ENTERITIS FOLLOWING ORTHOTOPIC LIVER TRANSPLANTATION J Leonard, JE Hay A 50 year old male underwent deceased donor orthotopic liver transplantation for advanced liver disease secondary to primary biliary cirrhosis. He had not received medical care in 18 months. The patient presented with worsening jaundice, ascites, peripheral edema, and severe debilitation. He was listed for liver transplantation with an initial MELD of 28 and Child-Turcotte-Pugh Class B (score 10). The patient was CMV IgG positive at 8 AU/mL (normal <4 AU/mL) pre-transplant.
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
His health deteriorated in hospital and prior to surgery support in the intensive care unit was needed for complications including E. coli bacteremia, spontaneous bacterial peritonitis (culture positive for Klebsiella), hepatorenal syndrome requiring CVVHD, and Grade 3 encephalopathy. He underwent liver transplantation 21 days after admission, receiving an organ from a CMV positive donor. Prophylactic acyclovir 400 mg orally twice daily was started as per the protocol at our facility on post-transplant day 1. His immunosuppression regimen consisted of daclizumab, methylprednisolone, and mycophenolate mofetil. Mild acute cellular rejection that was noted on a routine liver biopsy post-transplant day 8 was treated with methylprednisolone.
Post transplant day 4 he began to pass maroon colored stool. The bleeding continued and endoscopy was performed 3 days later. No blood was seen in the upper gastrointestinal tract. Visualization during colonoscopy was poor due to retained blood and feces but ulcers were seen in the terminal ileum, histology consistent with cytomegalovirus (CMV) inclusions. The patient was switched from acyclovir to intravenous gancyclovir. Testing for serum CMV DNA via PCR was negative. Unfortunately his bleeding did not settle and in total he received 24 units of packed red blood cells. He underwent an uncomplicated right hemicolectomy post-transplant day 18. There was no histological evidence of residual CMV in the resection specimen. The patient slowly recovered and was able to be discharged from hospital.
CMV complications post organ transplant have been well described but usually not during the first post-operative month. This early presentation may have been due to the patient's advanced illness prior to transplant.