Resistance to combined ganciclovir and foscarnet therapy in a liver transplant recipient with possible dual-strain cytomegalovirus coinfection

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Liver Transplantation, Vol: 13, Issue: 10, Page: 1396-1400

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Rodriguez, John; Casper, Katherine; Smallwood, Gregory; Stieber, Andrei; Fasola, Carlos; Lehneman, Jennifer; Heffron, Thomas
foscarnet; ganciclovir; methylprednisolone sodium succinate; mycophenolic acid 2 morpholinoethyl ester; prednisone; tacrolimus; valganciclovir; virus DNA; adult; alcohol liver cirrhosis; article; blood sampling; case report; cytomegalovirus infection; donor; drug dose increase; drug dose reduction; drug response; drug withdrawal; gene amplification; gene mutation; gene sequence; graft recipient; human; liver failure; liver graft rejection; liver transplantation; male; postoperative period; priority journal; recurrent infection; reperfusion injury; superinfection; virus isolation; virus strain; wild type; Antibodies; Viral; Antiviral Agents; Cytomegalovirus; Cytomegalovirus Infections; DNA; Drug Resistance; Multiple; Drug Therapy; Combination; Fatal Outcome; Follow-Up Studies; Humans; Middle Aged; Polymerase Chain Reaction; Pharmacy and Pharmaceutical Sciences
article description
We present a case report of a cytomegalovirus (CMV)-seronegative, 58-year-old male who received a CMV-seropositive donor liver transplant without CMV prophylaxis. On postoperative day 30, the patient developed primary CMV disease that responded to ganciclovir. On postoperative day 114, however, he was diagnosed with recurrent CMV infection. Despite aggressive, combined antiviral treatment with ganciclovir and foscamet and reduction of immunosuppression, viral clearance was never achieved. Serum samples were collected throughout the infectious process for viral DNA analysis. Portions of the UL97 and UL54 genes were amplified and compared to the AD169 wild-type strain. Sequencing studies revealed the presence of mutations in viral isolates obtained after clinical resistance was observed. These mutations were not present in samples obtained during the primary CMV infection. Our findings suggest the presence of coinfection with at least 2 different strains of CMV rather than induction of mutations after ganciclovir therapy. © 2007 AASLD.