Cocchi S, Di Benedetto F, Codeluppi M, Guaraldi G, Lauro A, Bagni A, Pecorari M, Gennari W, Quintini C, Esposito R, Pinna A D
Department of Internal Medicine and Medical Specialties, Infectious Diseases Clinic, University of Modena and Reggio Emilia, Via del Pozzo 71, 41100 Modena, Italy.
Dig Liver Dis. 2006 Jun;38(6):429-33. doi: 10.1016/j.dld.2005.07.005. Epub 2005 Sep 19.
Although advances in immunosuppressive therapy have led to increased survival of solid organ transplantation recipients, it is well established that current protocols have been associated with an increased risk of developing tissue-invasive infections. In particular, cytomegalovirus still represents an important cause of morbidity. We report a case of cytomegalovirus infection involving the graft ileum with documented necrotising enteritis that developed after small bowel transplantation. The patient, a 56-year-old Caucasian female with a postsurgery short bowel syndrome, underwent a small bowel transplantation. Immunosuppression was maintained by combination of tacrolimus, steroids and daclizumab. Both the donor and the recipient were serologically negative for cytomegalovirus IgG. Nevertheless, ganciclovir prophylaxis was given for 21 days after surgery, as standard procedure. On hospital day 174, routine pp65 antigenaemia resulted positive (14/200,000 peripheral blood leukocytes). The patient was asymptomatic and preemptive ganciclovir therapy was instituted. In the following 3 days, due to a cytomegalovirus antigenaemia increase, ganciclovir was changed to foscarnet with subsequent virological response (7/200,000 peripheral blood leukocytes, on day 181). Two days later, the patient complained of acute abdominal pain and she underwent surgery for the diagnosis. Since the intraoperative findings consisted of a diffuse acute purulent peritonitis, the intestinal graft, together with native rectum, was removed. Biopsy specimens showed evidence of tissue-invasive cytomegalovirus infection. Postsurgery, the patient developed septic shock and died on day 198 as a consequence of multiple organ failure.
尽管免疫抑制疗法的进展提高了实体器官移植受者的存活率，但目前已明确，现行方案与发生组织侵袭性感染的风险增加相关。特别是巨细胞病毒仍是发病的重要原因。我们报告一例小肠移植后发生的巨细胞病毒感染累及移植回肠并伴有坏死性肠炎确诊病例。患者为一名56岁的白种女性，患有术后短肠综合征，接受了小肠移植。通过他克莫司、类固醇和达利珠单抗联合维持免疫抑制。供者和受者的巨细胞病毒IgG血清学检测均为阴性。尽管如此，按照标准程序，术后给予更昔洛韦预防性治疗21天。在住院第174天，常规pp65抗原血症检测结果呈阳性（每200,000外周血白细胞中有14个）。患者无症状，开始给予抢先性更昔洛韦治疗。在接下来的3天里，由于巨细胞病毒抗原血症增加，将更昔洛韦改为膦甲酸钠，随后出现病毒学反应（在第181天，每200,000外周血白细胞中有7个）。两天后，患者主诉急性腹痛，接受手术以明确诊断。由于术中发现为弥漫性急性化脓性腹膜炎，切除了移植肠段及原直肠。活检标本显示有组织侵袭性巨细胞病毒感染的证据。术后，患者发生感染性休克，于第198天因多器官功能衰竭死亡。
