Case Studies

 Case 8.2 Primary cytomegalovirus infection in a renal transplant recipient

A 22-year-old welder was given a cadaveric renal graft after a month of haemodialysis for end-stage renal failure. His immediate postoperative course was uneventful and he was discharged home on maintenance immunosuppressive therapy (cyclosporin A 5mg/kg, prednisolone 30mg and azathioprine 75mg daily).

He was readmitted on the 37th day with general malaise, muscle aches and fever but able to maintain a reasonable urine output (1700ml/24h). On examination, he had tender muscles and hepatomegaly; the transplanted kidney was not tender. Investigation showed a leucopenia but a normal serum creatinine.

In view of the leucopenia, azathioprine was withheld for 8 days, and intravenous corticosteroids were substituted. However, his serum creatinine began to rise and urine output fell necessitating haemodialysis. Stored pretransplant serum samples showed no evidence of anticytomegalovirus (CMV) antibodies or CMV antigen by polymerase chain reaction (PCR) analysis. IgM anti-CMV antibodies were detected in a current serum sample accompanied by a positive PCR signal for CMV antigen. These findings indicated primary CMV infection in the recipient due to transplantation of a CMV-positive kidney into a CMV-negative recipient. He made a complete recovery following prompt treatment with a combination of ganciclovir (a CMV-specific drug) and CMV-specific immune globulin.