INTRODUCTION: The incidence of CMV infection and disease is higher among lung transplant recipients than among recipients of other solid organ transplants, with an estimated incidence ranging between 30% and 86%. The term CMV infection applies to a condition in which there is evidence of CMV replication whether or not symptoms are present. The term CMV disease indicates CMV infection with attributable symptoms. Lung transplant CMV infections can be detected by a variety of diagnostic methods including antigenemia assays, nucleic acid amplification and hybridization. Transbronchial biopsy specimens that demonstrate characteristic viral cytopathic effect and/or cells immunohistochemically positive for CMV antigen are specific for CMV pneumonitis. Although the diagnostic utility of transbronchial biopsy for the diagnosis of CMV infection is without dispute, relative sparing of the bronchial wall by transplant CMV infection has been noted by some authors.
CASE PRESENTATION: A 55 year old man underwent bilateral lung transplantation for pulmonary fibrosis from a CMV positive donor negative recipient 1year prior. His course was complicated by the development of bilateral bronchial stenosis at the anastomotic sites requiring stent placement, as well as stenosis of the bronchus intermedius requiring bronchoplasty. 4 months later he developed a chronic cough. He was then diagnosed with pulmonary tuberculosis and underwent treatment for 6 months however continued to be symptomatic with decline in FEV1. A CT scan revealed a raised lesion distal to the left main stent. Bronchoscopy revealed what seemed to be granulation tissue proximal and distal to the stent with distal lesion being larger. Bronchoalveolar lavage obtained grew Pseudomonas aeruginosa and the patient was treated with Ciprofloxacin. CMV PCR done at that time was negative. A repeat bronchoscopy after the course of antibiotic shows increase in sizes of lesions and endobronchial biopsy done showed viral inclusions characteristic of CMV. Repeat CMV PCR was positive with 3,500 copies. The patient was started on IV ganciclovir and IV CMV immune globulin with conversion to negative PCR in 3 days. The patient underwent rigid bronchoscopy with removal of the LMSB stent, and replacement with an ultraflex partially covered stent due to severe bronchomalacia with improvement in FEV1.
DISCUSSION: Airway complications are a significant source of morbidity and mortality. Improved surgical techniques, newer immunosuppressive agents and better medical management have led to an improvement in lung transplantation outcomes. The list of pathologic processes that can manifest as an endobronchial polyp or mass is potentially long. More pertinent to the lung transplant population are suture granulomas and inflammatory polyps. Focal CMV infection mimicking a tumor mass has been described in a lung transplant recipient. During our literature review, we found 3 reported cases of lung transplant recipients whose endobronchial biopsy specimens showed CMV infection. The two major approaches to CMV prevention are prophylaxis and preemptive treatment. The majority of members of an international consensus panel favored universal prophylaxis over preemptive treatment for D+/R- transplant recipients. Recent studies provide evidence for 12 months of valganciclovir as the most effective approach to long-term CMV prevention after lung transplantation.
CONCLUSIONS: Endobronchial lesions involving CMV have received little attention. Biopsy of endobronchial lesions in lung transplant recipients should be pursued to obtain a definitive diagnosis.
Reference #1 Naber JM, Palmer SM, Howell DN. Cytomegalovirus infection presenting as bronchial polyps in lung transplant recipients. The Journal of Heart and Lung Transplantation 2005;24:2109-13.
Reference #2 Kotton CN, Kumar D, Caliendo AM, et al: International consensus guidelines on the management of cytomegalovirus in solid organ transplantation. Transplantation 89:779, 2010.
Reference #3 Copeland, CAF, Davis, WA, Snyder L, Banks, M, Palmer, SM. Long-term efficacy and safety of 12 months of valganciclovir prophylaxis compared with 3 month after lung transplantation: A single-center, long-term follow-up analysis from a randomized, controlled CMV prevention trial. The Journal of Heart and Lung Transplantation 2011
DISCLOSURE: The following authors have nothing to disclose: Emily Aventura, Reinaldo Rampolla
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