A Case of Cytomegalovirus-Induced Arthritis after Lymphocyte-Depleting Therapy for Kidney Allograft Rejection

Richard Fuquay, James Eric Cooper

Health Science Center Division of Renal Diseases and Hypertension, Transplant Center, University of Colorado Denver, Aurora, USA.
Health Science Center Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, USA.

DOI: 10.4236/ojneph.2012.21001                

Abstract

Cytomegalovirus viremia and tissue-invasive disease are common after kidney transplantation. Chemoprophylaxis has made substantial improvement in this clinical problem. Here we report a 29-year-old woman who had kidney allograft rejection and received lymphocyte-depleting therapy. She presented with a new oligo-arthritis that led to 2 successive arthrocenteses. The etiology of the inflammation could not be determined initially. On the second arthrocentesis, a synovial fluid cytomegalovirus polymerase chain reaction test was positive. The patient responded to treatment with valganciclovir, had negative follow-up serum cytomegalovirus polymerase chain reaction tests, and experienced resolution of her joint inflammation. We review briefly the data for cytomegalovirus chemoprophylaxis, preemptive screening, and treatment recommendations.

Keywords

Cytomegalovirus (Mesh); Arthritis (Mesh); Kidney Transplantation (Mesh); Immunosuppression (Mesh); Chemoprevention (Mesh); Valganciclovir (Mesh)

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	C. N. Kotton, “Management of Cytomegalovirus Infection in Solid Organ Transplantation,” Nature Reviews Nephrology, Vol. 6, 2010, pp. 711-721. doi:10.1038/nrneph.2010.141
[2]	S. Sagedal, A. Hartmann, K. P. Nordal, K. Osnes, T. Leivestad, A. Foss, M. Degré, P. Fauchald and H. Rollag, “Impact of Early Cytomegalovirus Infection and Disease on Long-Term Recipient and Kidney Graft Survival,” Kidney International, Vol. 66, 2004, pp. 329-337. doi:10.1111/j.1523-1755.2004.00735.x
[3]	C. Contamin, J. P. Brion, F. Bayle, P. Morand, M. Peo’ch and P. Vialtel, “A Case of Arthritis Caused by Cytomegalovirus after Kidney Transplantation,” Transplant Infectious Disease, Vol. 6, No. 2, 2004, pp. 87-89. doi:10.1111/j.1399-3062.2004.00052.x
[4]	H. M. Friedman, T. Pincus, P. Gibilisco, D. Baker, J. P. Glazer, S. A. Plotkin and H. R. Schumacher, “Acute Monoarticular Arthritis Caused by Herpes Simplex Virus and Cytomegalovirus,” The American Journal of Medicine, Vol. 69, No. 2, 1980, pp. 241-247. doi:10.1016/0002-9343(80)90384-8
[5]	L. J. Burns and R. D. Gingrich, “Cytomegalovirus Infection Presenting as Polyarticular Arthritis Following Autologous BMT,” Bone Marrow Transplant, Vol. 11, No. 1, 1993, pp. 77-79.
[6]	J. D. MacFarlane, R. S. Filo and K. D. Brandt, “Joint Effusions after Kidney Transplantation,” Arthritis & Rheumatism, Vol. 22, No. 2, 1979, pp. 164-169. doi:10.1002/art.1780220209
[7]	J. J. Cush and P. E. Lipsky, “Approach to Articular and Musculoskeletal Disorders,” In: D. L. Longo, D. L. Kasper, J. L. Jameson, A. S. Fauci and S. L. Hauser, Eds., Harrison’s Principles of Internal Medicine, McGraw-Hill, New York, 2012.
[8]	S. J. McPhee and M. Papadakis, “Current Medical Diagnosis and Treatment,” 51st Edition, McGraw-Hill Medical, New York, 2010.
[9]	T. C. Noordzij, K. M. L. Leunissen and J. P. Van Hooff, “Renal Handling of Urate and the Incidence of Gouty Arthritis during Cyclosporine and Diuretic Use,” Transplantation, Vol. 52, No. 1, 1991, pp. 64-67. doi:10.1097/00007890-199107000-00013
[10]	C. E. Chamberlain, S. R. Penzak, R. M. Alfaro, R. Wesley, C. E. Daniels, D. Hale, A. D. Kirk and R. B. Mannon, “Pharmacokinetics of Low and Maintenance Dose Valganciclovir in Kidney Transplant Recipients,” American Journal of Transplantion, Vol. 8, No. 6, 2008, pp. 1297-1302. doi:10.1111/j.1600-6143.2008.02220.x
[11]	A. Asberg, A. Humar, H. Rollag, A. G. Jardine, H. Mouas, M. D. Pescovitz, D. Sgarabotto, M. Tuncer, I. L. Noronha and A. Hartmann, “Oral Valganciclovir Is Noninferior to Intravenous Ganciclovir for the Treatment of Cytomegalovirus Disease in Solid Organ Transplant Recipients,” American Journal of Transplantation, Vol. 7, No. 9, 2007, pp. 2106-2113. doi:10.1111/j.1600-6143.2007.01910.x
[12]	M. A. Schnitzler, J. A. Lowell, K. L. Hardinger, S. B. Boxerman, T. C. Bailey and D. C. Brennan, “The Association of Cytomegalovirus Sero-Pairing with Outcomes and Costs Following Cadaveric Renal Transplantation Prior to the Introduction of Oral Ganciclovir CMV Prophylaxis,” American Journal of Transplantation, Vol. 3, No. 4, 2003, 445-451. doi:10.1034/j.1600-6143.2003.00069.x
[13]	E. M. Hodson, C. A. Jones, A. C. Webster, G. F. Strippoli, P. G. Barclay, K. Kable, D. Vimalachandra and J. C. Craig, “Antiviral Medications to Prevent Cytomegalovirus Disease and Early Death in Recipients of Solid-Organ Transplants: A Systematic Review of Randomised Controlled Trials,” The Lancet, Vol. 365, No. 9477, 2005, pp. 2105-2115. doi:10.1016/S0140-6736(05)66553-1
[14]	A. Asberg, A. Humar, A. G. Jardine, H. Rollag, M. D. Pescovitz, H. Mouas, A. Bignamini, H. T?z, I. Dittmer, M. Montejo and A. Hartmann, “Long-Term Outcomes of CMV Disease Treatment with Valganciclovir versus IV Ganciclovir in Solid Organ Transplant Recipients,” American Journal of Transplantation, Vol. 9, No. 5, 2009, pp. 1205-1213. doi:10.1111/j.1600-6143.2009.02617.x
[15]	M. Battiwalla, Y. Wu, R. P. S. Bajwa, M. Radovic, N. G. Almyroudis, B. H. Segal, P. K. Wallace, R. Nakamura, S. Padmanabhan, T. Hahn and P. L. McCarthy, “Ganciclovir inhibits Lymphocyte Proliferation by Impairing DNA Synthesis,” Biology of Blood and Marrow Transplantion, Vol. 13, No. 7, 2007, pp. 765-770. doi:10.1016/j.bbmt.2007.03.009
[16]	J. A. Khoury, G. A. Storch, D. L. Bohl, R. M. Schuessler, S. M. Torrence, M. Lockwood, M. Gaudreault-Keener, M. J. Koch, B. W. Miller, K. L. Hardinger, M. A. Schnitzler and D. C. Brennan, “Prophylactic versus Preemptive Oral Valganciclovir for the Management of Cytomegalovirus Infection in Adult Renal Transplant Cecipients,” American Journal of Transplantation, Vol. 6, No. 9, 2006, pp. 2134-2143. doi:10.1111/j.1600-6143.2006.01413.x
[17]	C. N. Kotton, D. Kumar, A. M. Caliendo, A. Asberg, S. Chou, D. R. Snydman, U. Allen and A. Humar, “International Consensus Guidelines on the Management of Cytomegalovirus in Solid Organ Transplantation,” Transplantation, Vol. 89, No. 7, 2010, pp. 779-795. doi:10.1097/TP.0b013e3181cee42f
[18]	V. Kliem, L. Fricke, T. Wollbrink, M. Burg, J. Radermacher and F. Rohde, “Improvement in Long-Term Renal Graft Survival due to CMV Prophylaxis with Oral Ganciclovir: Results of a Randomized Clinical Trial,” American Journal of Transplantation, Vol. 8, No. 5, 2008, pp. 975-983. doi:10.1111/j.1600-6143.2007.02133.x
[19]	L. N. Small, J. Lau and D. R. Snydman, “Preventing Post-Organ Transplantation Cytomegalovirus Disease with Ganciclovir: A Meta-Analysis Comparing Prophylactic and Preemptive Therapies,” Clinical Infectious Disease, Vol. 43, No. 7, 2006, pp. 869-880. doi:10.1086/507337
[20]	F. L. Luan, M. Kommareddi and A. O. Ojo, “Universal Prophylaxis Is Cost Effective in Cytomegalovirus Serology-Positive Kidney Transplant Patients,” Transplantation, Vol. 91, No. 2, 2011, pp. 237-244. doi:10.1097/TP.0b013e318200000c
[21]	F. L. Luan, L. J. Stuckey, J. M. Park, D. Kaul, D. Cibrik and A. Ojo, “Six-Month Prophylaxis Is Cost Effective in Transplant Patients at High Risk for Cytomegalovirus Infection,” Journal of American Society of Nephrology, Vol. 20, No. 11, 2009, pp. 2449-2458. doi:10.1681/ASN.2008111166
[22]	D. C. Brennan, “Cytomegalovirus in Renal Transplantation,” Journal of American Society of Nephrology, Vol. 12, No. 4, 2001, pp. 848-855.
[23]	P. L. Hibberd, N. E. Tolkoff-Rubin, A. B. Cosimi, R. T. Schooley, D. Isaacson, M. Doran, A. Delvecchio, F. L. Delmonico, H. Auchincloss Jr. and R. H. Rubin, “Symptomatic Cytomegalovirus Disease in the Cytomegalovirus Antibody Seropositive Renal Transplant Recipient Treated with OKT31,2,” Transplantation, Vol. 53, No. 1, 1992, pp. 68-72. doi:10.1097/00007890-199201000-00013