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Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
Nonproductive cough, rhinorrhea, dyspnea, fever/chills, pneumonitis
Demonstration of imputability or root cause:
Recipient CMV IgG and IgM negative prior to transplant, on immune suppression receiving tacrolimus and MMF; received 4 weeks of 225 mg OD Vancyclovir as per local protocol. One week after discontinuation of CMV prophylaxis the recipient developed symptoms compatible with CMV infection. Approximately 6-8 weeks after transplant, serum CMV PCR was positive. Cornea-only donors are not tested for CMV serostatus and no donor sample remained available for testing. Authors presumed the donor was likely to be seropositive for CMV given the age (66 years, seroprevalence >80% in individuals over age 60) but this is insufficient to regard this as a donor-derived infection.
Suggest new keywords:
keratolimbal allograft transplantation; CMV
mycophenolate; tacrolimus; valganciclovir; prophylaxis; systemic immunosuppression
Probable Donor-Derived Cytomegalovirus Disease After Keratolimbal Allograft Transplantation. Cheung AY et al. Cornea. 2017 Aug;36(8):1006-1008
Second editor- Please hold. This needs further review. Keratolimbal stem cells are usually expanded ex vivo and grown on a scaffold (amniotic membrane or other) so I am not sure why a donor -derived CMV infection is being raised in this paper. I will need to check. The CMV VL finding does not align with an end organ disease caused by CMV, and there is no serology either. I fear there are many pieces missing. (Ines) Independet Review by Carl-Ludwig: In a cerato-limbal grafts we have not a isolated cornea, we have stem cells transplanted with the graft and there is indication for systematic immunosuppression with the risk of reactivation or de-novo infection for CMV. Interestingly in the reported case one week after discontinuing CMV propylaxis (after 1 month) the recipient developed symptoms compatible to CMV infection. After a time interval of another week CMV was detected by PCR in the bood. CMV infection seemed to resolve in symptoms after systemic treatment. In this case we only know, that the recipient was anti-CMV IgG & IgM not reactive pre-transplant. About the donor and its’ age we have no data. No data exist about other exposure risks to acquire CMV infection during immunosuppression. The recipient’s condition improved after involvement of a transplant infectious disease expert. In conclusion, in tissue transplanatation requiring systemic immunosuppression the equivalent care about infections is advisable as it is done in organ recipients. This study fails to confirm a donor derived infection – but it cannot be ruled out; also it is possible that the infection has been acquired while the recipient was immunosuppressed. Therefore awareness must exist about reactivation of CMV-infection in D-/R+ or D+/R+ as well as de-novo infection in D-/R- or D+/R- cases. Whether anti-CMV screening in cornea donors should be recommened or not is a question of further studies – in advanced aged donors CMV infection has occurred frequenly. Therefore without providing addtional infomation no conclusion are possible.
Expert comments for publication:
In keratolimbal grafts there are stem cells transplanted with the graft with need of systemic immunosuppression. In this case, risk of acquisition of CMV from other sources is not considered or discussed. This study fails to confirm a donor derived infection. Insufficient evidence is provided to support the need for screening for CMV IgG in keratolimbal tissue donors.