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bone marrow transplant&#46;<span class="elsevierStyleSup">13&#44;14</span></p><p class="elsevierStylePara">We present the case of a 53-year-old man&#44; subjected to kidney transplant&#44; who came to the emergency department with fever&#44; temperature 38&#46;5&#186;C over a 24-hour period&#44; with shivers&#44; mild diffuse abdominal pain&#44; asthenia&#44; anorexia&#44; and a decrease in diuresis volume&#46; The physical examination was normal and no important pathology was found from the tests performed at the emergency department&#58; normal X-ray&#59; normal blood and urine tests&#59; negative blood and urine cultures&#59; negative cytomegalovirus &#40;CMV&#41; early-antigen &#40;at that time&#44; CMV polymerase chain reaction &#40;PCR&#41; assays were not available in our hospital&#41;&#46; The symptoms worsened&#44; abdominal pain increased&#44; and on the CT scan we observed dilated small bowel loops due possibly to ischaemia or infection&#46; Given the findings and the worsening clinical symptoms&#44; we performed an exploratory laparotomy&#44; without observing anomalies&#46; A coagulase-negative staphylococcus grew in the peritoneal fluid&#44; which was treated with meropenem at 500mg every 12 hours&#46; Following the intervention&#44; the clinical symptoms improved despite having developed a post-operative paralytic ileus&#44; which improved spontaneously&#46; After a few days&#44; the patient presented with fever again&#44; and diarrhoea&#46; There were initially no traces of blood&#44; but he then presented with melaena&#44; associated with neurological deterioration&#44; hepatosplenomegaly and hepatic function alterations&#44; anaemia and thrombocytopaenia&#46; New tests were requested&#58; positive CMV early-antigen&#59; CMV PCR assay above 100&#160;000 copies&#47;ml&#46; Eso-Gastro-Duodenoscopy &#40;EGD&#41;&#58; infected oesophagus&#46; Analytical tests showed&#58; GOT&#47;GPT&#58; 135&#47;156IU&#47;l&#59; LDH&#58; 558IU&#47;l&#59; sodium&#58; 130mEq&#47;l&#44; fibrinogen&#58;133mg&#47;dl&#44; haemoglobin&#58; 9&#46;2 g&#47;dl&#59; and haematocrit&#58; 26&#46;8&#37;&#59; platelets&#58; 48 000&#181;l with normal leukocytes &#40;normal formula&#58; 5500&#181;l&#41;&#44; significant increase in triglycerides &#40;738mg&#47;dl&#41;&#44; progressive deterioration of kidney function &#40;creatinine around 4-5mg&#47;dl&#41;&#46; Normal haptoglobin&#44; negative indirect Coombs test&#46; Peripheral blood smear&#58; few schistocytes with no reticulocyte&#46; Bone marrow aspiration&#58; compatible with haemophagocytic syndrome &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">Given these findings&#44; the patient was diagnosed with CMV-associated haemophagocytic syndrome<span class="elsevierStyleBold">&#46; </span>The patient visited infection diseases unit and the following therapeutic regimen was started&#58; anti-CMV with ganciclovir 50mg&#47;12h and non-specific i&#46;v&#46; gamma globulin 30g&#47;48h&#44; and methylprednisolone bolus were indicated for haemophagocytic syndrome&#46; The patient continued to take cyclosporine at low doses &#40;around 50ng&#47;ml&#41;&#46; Despite being treated&#44; the patient&#8217;s general and neurological condition worsened and he was finally admitted to the ICU for saturation&#44; where he died 12 hours after admission due to multiple organ failure&#46; The autopsy showed&#58; disseminated CMV infection&#44; mainly affecting the digestive tract and lung &#40;Figure 2&#41; and reactive haemophagocytic syndrome &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">The prevalence of haemophagocytic syndrome in kidney transplant patients is 0&#46;4&#37;&#44;<span class="elsevierStyleSup">11</span> which makes it a rare complication in this patient group&#46; Furthermore&#44; the most common aetiology for these patients is that secondary to an infection&#46;<span class="elsevierStyleSup">14</span> These patients have poor prognosis meaning that early diagnosis is essential to enable starting therapy early&#46; There is no consensus on treatment strategies&#44; and several treatments have been proposed&#44; such as steroids and cyclosporine&#44;<span class="elsevierStyleSup">14</span> specific immunoglobulin&#44; treating the aetiological agent&#44; etc&#46;</p><p class="elsevierStylePara">On the other hand&#44; CMV-associated infections in kidney transplant patients is a common complication&#44; although its incidence and repercussion is decreasing due to the prophylaxis employed&#46;<span class="elsevierStyleSup">15</span> In spite of this&#44; it is a diagnosis that we should take into account when a transplant patient&#8217;s general condition deteriorates&#44; because the complications for this infectious profile are all serious&#46; Early diagnosis and starting correct therapy greatly improves prognosis&#46;</p><p class="elsevierStylePara">Haemophagocytic syndrome is a rare complication following kidney transplantation&#46; Furthermore&#44; it is a clinical entity that must be considered during the differential diagnosis of these patients&#44; especially if associated with fever&#44; organomegaly and pancytopenia&#46; Bone marrow aspiration allows for a clearer diagnosis&#44; whereas blood test analyses only enable us to make presumptions &#40;pancytopaenia&#44; hepatic kidney function alteration&#44; increase in LDH&#44; decreased fibrinogen&#44; increased triglycerides&#44; hyponatraemia&#44; etc&#41;&#46; Viral infection is the most common triggering agent for immunosuppressed patients&#46; The problem is that there is still no specific treatment&#44; meaning that transplant patient survival is very low&#44; and if patients were to survive&#44; the kidney graft does not often function correctly&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10639&#95;108&#95;15837&#95;en&#95;10639f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10639_108_15837_en_10639f1.jpg" alt="Trichrome staining&#46; Histiocytes with red blood cells indicating haematophagous activity in bone marrow&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Trichrome staining&#46; Histiocytes with red blood cells indicating haematophagous activity in bone marrow&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10639&#95;108&#95;15838&#95;en&#95;10639f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10639_108_15838_en_10639f2.jpg" alt="Immunoperoxidase staining&#46; Cells containing CMV in the intestinal tissue&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Immunoperoxidase staining&#46; Cells containing CMV in the intestinal tissue&#46;</p>"
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Vol. 31. Issue. 2.March 2011
Pages 0-240
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Cytomegalovirus-associated haemophagocytic syndrome in a kidney transplant patient
Síndrome hemofagocítico reactivo a infección por CMV en paciente trasplantado renal
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S.. BEA GRANELLa, S.. BEA GRANELLb, I.. BENEYTO CASTELLOb, D.. RAMOS ESCORIHUELAb, J.. SÁNCHEZ PLUMEDb, P.. SÁNCHEZ PÉREZb, J.. HERNÁNDEZ-JARASb, S.. RIVASc
a Servicio de Nefrología, Hospital Universitario La Fe, Valencia, Spain,
b Servicio de Nefrología, Hospital Universitario La Fe, Valencia,
c Servicio de Anatomía Patológica, Hospital Universitario La Fe, Valencia,
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To the Editor,

Haemophagocytic syndrome is a rare clinical condition characterised by a generalised, benign proliferation of histiocytes with significant haemophagocytic activity.1-3 The aetiology of these symptoms can be separated into two groups: primary or genetically determined, or secondary: virus, bacteria, fungus, parasites, neoplasia, collagen, immunodeficiency or drugs.1-7 Clinical symptoms include fever, hepatosplenomegaly, lymphadenomegaly, neurological symptoms, oedema and rashes.1,2,8,9 The most important laboratory findings are: pancytopaenia, hypertriglyceridaemia, hypofibrinogenaemia, hyponatraemia, hypoproteinaemia, increased levels of hepatic enzymes, increased amount of LDH and ferritin, pleocytosis in LCR and defective activity of natural killer (NK) cells.10 The histological analysis found haemophagocytosis in the bone marrow, spleen and lymph nodes. There were no malignant findings and diagnosis was possible with 2% of haemophagocytic cells.1-3 Haemophagocytic syndrome has a poor prognosis despite treatment, with an average survival of 2 weeks after the onset of the clinical symptoms. Survival can reach 60% at 5 years if there is an adequate response to treatment.11,12 Agents that interrupt histiocyte function and macrophage activation are therapeutic alternatives, such as etoposide, steroids, high-dose i.v. Ig, cyclosporine A, anti-thymocyte globulin, anti- TNF antibodies, and in some cases, bone marrow transplant.13,14

We present the case of a 53-year-old man, subjected to kidney transplant, who came to the emergency department with fever, temperature 38.5ºC over a 24-hour period, with shivers, mild diffuse abdominal pain, asthenia, anorexia, and a decrease in diuresis volume. The physical examination was normal and no important pathology was found from the tests performed at the emergency department: normal X-ray; normal blood and urine tests; negative blood and urine cultures; negative cytomegalovirus (CMV) early-antigen (at that time, CMV polymerase chain reaction (PCR) assays were not available in our hospital). The symptoms worsened, abdominal pain increased, and on the CT scan we observed dilated small bowel loops due possibly to ischaemia or infection. Given the findings and the worsening clinical symptoms, we performed an exploratory laparotomy, without observing anomalies. A coagulase-negative staphylococcus grew in the peritoneal fluid, which was treated with meropenem at 500mg every 12 hours. Following the intervention, the clinical symptoms improved despite having developed a post-operative paralytic ileus, which improved spontaneously. After a few days, the patient presented with fever again, and diarrhoea. There were initially no traces of blood, but he then presented with melaena, associated with neurological deterioration, hepatosplenomegaly and hepatic function alterations, anaemia and thrombocytopaenia. New tests were requested: positive CMV early-antigen; CMV PCR assay above 100 000 copies/ml. Eso-Gastro-Duodenoscopy (EGD): infected oesophagus. Analytical tests showed: GOT/GPT: 135/156IU/l; LDH: 558IU/l; sodium: 130mEq/l, fibrinogen:133mg/dl, haemoglobin: 9.2 g/dl; and haematocrit: 26.8%; platelets: 48 000µl with normal leukocytes (normal formula: 5500µl), significant increase in triglycerides (738mg/dl), progressive deterioration of kidney function (creatinine around 4-5mg/dl). Normal haptoglobin, negative indirect Coombs test. Peripheral blood smear: few schistocytes with no reticulocyte. Bone marrow aspiration: compatible with haemophagocytic syndrome (Figure 1).

Given these findings, the patient was diagnosed with CMV-associated haemophagocytic syndrome. The patient visited infection diseases unit and the following therapeutic regimen was started: anti-CMV with ganciclovir 50mg/12h and non-specific i.v. gamma globulin 30g/48h, and methylprednisolone bolus were indicated for haemophagocytic syndrome. The patient continued to take cyclosporine at low doses (around 50ng/ml). Despite being treated, the patient’s general and neurological condition worsened and he was finally admitted to the ICU for saturation, where he died 12 hours after admission due to multiple organ failure. The autopsy showed: disseminated CMV infection, mainly affecting the digestive tract and lung (Figure 2) and reactive haemophagocytic syndrome (Figure 1).

The prevalence of haemophagocytic syndrome in kidney transplant patients is 0.4%,11 which makes it a rare complication in this patient group. Furthermore, the most common aetiology for these patients is that secondary to an infection.14 These patients have poor prognosis meaning that early diagnosis is essential to enable starting therapy early. There is no consensus on treatment strategies, and several treatments have been proposed, such as steroids and cyclosporine,14 specific immunoglobulin, treating the aetiological agent, etc.

On the other hand, CMV-associated infections in kidney transplant patients is a common complication, although its incidence and repercussion is decreasing due to the prophylaxis employed.15 In spite of this, it is a diagnosis that we should take into account when a transplant patient’s general condition deteriorates, because the complications for this infectious profile are all serious. Early diagnosis and starting correct therapy greatly improves prognosis.

Haemophagocytic syndrome is a rare complication following kidney transplantation. Furthermore, it is a clinical entity that must be considered during the differential diagnosis of these patients, especially if associated with fever, organomegaly and pancytopenia. Bone marrow aspiration allows for a clearer diagnosis, whereas blood test analyses only enable us to make presumptions (pancytopaenia, hepatic kidney function alteration, increase in LDH, decreased fibrinogen, increased triglycerides, hyponatraemia, etc). Viral infection is the most common triggering agent for immunosuppressed patients. The problem is that there is still no specific treatment, meaning that transplant patient survival is very low, and if patients were to survive, the kidney graft does not often function correctly.

Figure 1. Trichrome staining. Histiocytes with red blood cells indicating haematophagous activity in bone marrow.

Figure 2. Immunoperoxidase staining. Cells containing CMV in the intestinal tissue.

Bibliography
[1]
Kenneth L, McClain. Up to Date. Haemophagocytic lymphohistiocytosis. Versión 18.2. Mayo 2010.
[2]
Artigues Barceló A, Ferragut Reus M, Sánchez C, Amengual L, Matanza L, Sanz Parras MS. Síndrome hemofagocítico y !infoma cutáneo de células T. An Med Interna (Madrid) 2004;21:131-4.
[3]
Janka G, Imashuku S, Elinder G, Schneider M, Henter JI. Infection- and malignancy-associated hemophagocytic syndromes. Secondary hemophagocytic lymphohistiocytosis. Hematol Oncol Clin North Am 1998;12:435-44.  [Pubmed]
[4]
Stephan JL, Kone-Paut L, Galambrun C, Mouy R, Bader-Meunier B, Prieur AM. Reactive haemophagocytic syndrome in children with inflammatory disorders. A retrospective study of 24 patients. Rheumatology 2001;40(11):1285-92.
[5]
Boehler A, Schaffner A, Salomon F, et al. CMV disease of late onset following renal transplantation: a potentially fatal entity. Scand J Infect Dis 1994;26:369. [Pubmed]
[6]
Kürsat S, Cagirgan S, Ok E, et al. Haemophagocytic-histiocytic syndrome in renal transplantation. Nephrol Dial Transplant 1997;12:1058. [Pubmed]
[7]
Mroczek E, Weisenburger D, Grierson H, Markin R, Purtilo D. Fatal infectious mononucleosis and virus associated hemophagocytic syndrome. Arch Pathol Lab Med1987;111:530-5.
[8]
De Kerguenec C, Hillaire S, Molinie V, et al. Hepatic manifestations of haemophagocytic syndrome: a study of 30 cases. Am J Gastroenterol 2001;96(3):852-7. [Pubmed]
[9]
Wong K, Chan J. Reactive hemophagocytic syndrome: a clinicopathologic study of 40 patients in an Oriental population. Am J Med 1992;93:177-80. [Pubmed]
[10]
Esumi N, Ikshima S, Hibi S, Todo S, Imashuku S. High serum ferritin level as a marker of malignant histiocytosis and virus-associated haemophagocytic syndrome. Cancer 1988;61(10):2071-6. [Pubmed]
[11]
Karras A, Thervet E, Legendre C. Haemophagocytic syndrome in renal transplant recipients: report of 17 cases and review of literature. Transplantation 2004;77(2):238-43. [Pubmed]
[12]
Risdall RJ, McKenna RW, Nesbit ME, et al. Virus-associated hemophagocytic syndrome: a benign histiocytic proliferation distinct
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