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

ABSTRACT

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.