New Onset Cmv Disease in Post Renal Transplant Patients in Association with Covid19 Infection - 2 Cases and Brief Review of Literature

BACKGROUND: Several cases of CMV syndrome and invasive CMV infection have been reported following COVID19 infection worldwide during COVID19 pandemic in both immunocompetent and immunosuppressed patients. AIM OF THE STUDY: We intend to discuss more about the interrelationship of COVID19 and CMV infection in renal transplant patients. METHOD(S): We discuss two clinical cases, and we present a brief review of literature. 30-year-old man with end-stage primary lupus nephritis underwent mother-to-son kidney transplantation. Post-transplant surgery the patient was discharged with 1.8 mg/ml baseline creatinine. After 3 months, he was admitted with complaints of fever for 4 days with no derangement of renal function. He tested positive for COVID 19 infection and was managed conservatively. Subsequently within 10 days, he was readmitted with chief complaints of loose stools abdominal pain and back pain with mildly raised creatinine and leukopenia. CMV PCR detected 128500 copies per ml. This patient was treated with injection ganciclovir and GM-CSF injection. Mycophenolate mofetil was withheld in view of CMV infection. However, the patient complained of persistent back pain with gradual decline in graft and renal function. With decreasing urine output, dialysis was initiated. Subsequently, the patient developed altered sensorium and had cardiac arrest. 34-year-old male with end-stage chronic nephritis had undergone cadaveric kidney transplantation. Post-transplant the patient had delayed onset graft function with baseline creatinine of 2 mgdl on the 10th post-operative day. Subsequently, the patient suffered from active antibody-mediated rejection, and the patient was managed with six cycles of plasmapheresis. One month later, the patient was admitted with fever and cough. The patient tested positive for COVID19 infection and was managed conservatively. Simultaneously, the patient developed multiple episodes of hematochezia pain in abdomen and diarrhea. Urine output was maintained with stable creatinine. Stool routine and microscopic examination revealed multiple RBCs few pus cells - however no parasite was detected. CMV PCR was positive with 3000 copies per ml. The patient was initially treated with injection ganciclovir and was switched to oral valganciclovir. The patient remained afebrile general condition improved with no further episodes of hematochezia and gradual decline of creatinine to baseline level. RESULT(S): In both our cases, COVID19 infection were managed conservatively, and CMV infection was treated with stoppage of mycophenolate mofetil and addition of ganciclovir injection and resulted into one positive and one negative clinical outcome. CONCLUSION(S): CMV reactivation after COVID 19 infection in renal transplant patient may be a common phenomenon. Further studies are immediately needed to know whether CMV viremia should be routinely tested in all renal transplant patients in India who get COVID19 infection. Studies are also required to determine if clinical outcomes of CMV disease after COVID19 infection in renal transplant patients are different from CMV disease outcomes in other renal transplant patients who have no history of immediately preceding COVID 19 infection.

Infective Endocarditis Pulmonary Septic Emboli Due to Mrsa in a Patient with Chronic End Stage Kidney Disease on Maintenance Hemodialysis a Case Report and Few Learning Points

BACKGROUND: Small percentage of catheter-related bloodstream infection may present atypically with persistent low-grade fever without chills and rigor and in some of these cases blood culture can be negative. These may lead to diagnostic confusion and delay in detection of the common entity of catheter-related blood stream infections. AIM OF THE STUDY: Case discussion with learning points METHODS: We report a case with multiple pictorial images and discuss differential diagnosis with few learning points. RESULT(S): 42-year-old male patient, a known case of end-stage chronic kidney disease on maintenance hemodialysis through a tunneled catheter, presented with a history of intermittent, low-to-moderate fever for 3 weeks. The fever associated with generalized weakness, night sweats but was not associated with chill and rigor. His past medical history included endstage chronic kidney disease due to chronic glomerulonephritis and was on maintenance hemodialysis thrice weekly for last 6 months through tunneled catheter in right IJV. On physical examination, the patient had tachycardia, normotension with a blood pressure of 120/70.mmHg, normal saturation at room air with respiratory rate of 20 /minute. On auscultation, there was reduced breath sounds on left side and normal heart sounds. The catheter site showed no heat, erythema, swelling, tenderness. Chest radiograph revealed left hydropneumothorax with multiple focal pulmonary nodular opacities. CECT chest showed left loculated hydropneumothorax with multiple cavitary nodules with reverse halo sign (Figures 1 and 2). Lab investigations showed significant leukocytosis with neurophilia, random serum glucose of 250.mg/dL, and D-dimer of 3624.ng/mL. Blood cultures from hemodialysis catheter and contralateral peripheral vein were negative for pathogenic bacteria, mycobacteria, and fungal etiology. Urine analysis was sterile and did not have pus cells. On day 4 of admission, patient had left axillary pain. On clinical examination, there was focal tenderness on examination in the left axilla. On ultrasonography, there was a small collection which was aspirated under ultrasound guidance and showed gram-positive bacteria on microscopy. Trans esophageal echocardiography revealed multiple tiny vegetations on right side of interatrial septum on tricuspid valve (Figure 3). Subsequent culture results showed methicillin resistant staphylococcus sensitive to clindamyin, vancomycin, linezolid, ciprofloxacin (Figure 4 and 5). The patient was started on vancomycin and ceftazidine on empirical basis for microscopic findings, and after subsequent culture revealed methicillin-resistant Staphylococcus aureus, he was treated with vancomycin. Permanent catheter was removed. Hemodialysis was continued through temporary right IJV catheter. Blood cultures were cleared from MRSA on hospital day ten. She got discharged home on intravenous Vancomycin for 6-8 weeks and was reported doing well on follow-up. CONCLUSION(S): The learning points are- 1. MRSA infection is common in chronic kidney disease patient on hemodialysis. 2. Clinical presentation of metastatic MRSA infection with infective endocarditis may be indolent with cardiovascular and respiratory stability with absence of fever spikes, chill, and rigor. 3. Common infective causes of cavitary nodules in lung are typical and atypical mycobacterial infection, fungal infection, and pyogenic septic emboli. 4. Uncommon infective causes of reverse halo sign on CT chest need to be remembered and include bacterial pneumonia, septic embolism, mycobacterial infection, invasive aspergillosis, in addition to common infective etiology of reverse halo sign like mucormycosis infection and COVID19 infection.