237 Ganciclovir Resistant Cytomegalovirus in a Renal Transplant Recipient: A Medical Challenge

Abstract

GANCICLOVIR RESISTANT CYTOMEGALOVIRUS IN A RENAL TRANSPLANT RECIPIENT: A MEDICAL CHALLENGE Aashish K Pandey, David B. Butcher Department of Nephrology and Hypertension St. John Hospital & Medical Center, Detroit, Michigan The PV 16000 study reported ganciclovir resistant cytomegalovirus (CMV) in 1.9% renal transplant recipients. The resistant strain may present amino acid deletions or substitutions in conserved regions of the UL97 protein, point mutation in the DNA polymerase (UL54) or both. We describe a case of a 54 year old African American female, who received a deceased donor renal allograft in August, 2009. CMV serology status was seronegative for the recipient and seropositive for donor. Patient had intermittent lapses in CMV prophylaxis due to missing medication followed by leucopenia. Her Immunosuppressant medications included Tacrolimus, Mycophenolate Mofetil and prednisone. One month post transplant, patient developed Acute AntibodyMediated rejection, and received treatment with Plasmapheresis, IV Immunoglobulin and Rituximab. A week later she developed CMV pneumonitis, and was started on Valganciclovir. A viral load of 381,000 was detected that progressively decreased to 44,800 over a period of 4 months. Patient continued to feel lethargic and was admitted again in the hospital. Her viral load had increased to 80,300. A genotypic testing for drug resistance was performed, and patient found to have a UL97 mutation with resistance at site L595S. Treatment was initiated on a combination synergistic regimen of one half dose of ganciclovir and one half dose of Foscarnet, which helped bring the viral load down to 17,300 in 3 weeks. Renal function remained stable with IV hydration. The intensity of immunosuppression, CMV seronegative status and intermittent CMV prophylactic treatment contributed to the development of ganciclovir resistant CMV infection in our renal transplant patient.