ESPN 50th Annual Meeting

ESPN 2017


 
Multi-drug resistant CMV viremia secondary to a rare viral mutation in paediatric kidney transplant recipient successfully treated with anti-proliferative cessation and immunoglobulins
RACHEL FOLWELL 1 GRAINNE WALSH 1 HELEN E JONES 1 EITHNE MACMAHON 2 JELENA STOJANOVIC 1

1- EVELINA LONDON CHILDRENS HOSPITAL, LONDON, UK
2- GUYS AND ST THOMAS NHS FOUNDATION TRUST,LONDON,UK
 
Introduction:

International Transplant Society for CMV Consensus Group advises ganciclovir, valganciclovir and foscarnet as treatment for CMV in transplant recipients. Viral DNA polymerase resistance mutations are rare but may be associated with cross resistance. We report a rare CMV mutation associated with resistance to all available medications in a CMV seronegative recipient treated with immunosuppression dose reduction and IVIG.

Material and methods:

Retrospective data analysis from medical records.

Results:

Sixteen year old girl with ESRD due to Alport Syndrome received deceased donor kidney transplant (mismatch 120, CMV Donor+/Recipient- , EBV Donor-/Recipient+). She received basilixumab on induction and her maintanance immunosuppression included tacrolimus, azathioprine and prednisolone. As per our centre protocol, she was started on valganciclovir prophylaxis for 90 days. Two months post-transplant, whilst on valganciclovir prophylaxis, she developed CMV viremia. Viral loads continued to rise (highest log 5.41) despite the treatment dose intravenous ganciclovir. She was found to have a rare CMV UL 54 mutation (POL gene deletion 981/982), associated with multidrug resistance. She had no evidence of CMV disease and stable graft function, and was managed with cessation of azathioprine and intravenous immunoglobulins (IVIG). CMV IgM was positive at 4 months, with IgG seroconversion demonstrated at 9 months post transplant with CMV PCR not detected from month 9 onwards. She developed borderline T cell mediated rejection successfully treated with high dose of oral prednisolone. Eighteen months post transplant, patient is well with stable graft function (estimated GFR 69ml/min/1.73m2) on CNI inhibitor and daily prednisolone only. Donor specific antibodies are not detected. To date, cytotoxic T cell response to CMV is negative but CMV remains undetectable.

Conclusions:

We report a case of multidrug resistant CMV viremia in a transplant recipient with primary CMV infection, managed with IVIG and cessation of anti-proliferative agent only with excellent patient outcome including preservation of good graft function.