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Primary cytomegalovirus infection causing a kidney transplant patient to develop cryoagglutinins and cryoglobulins
Primoinfección por citomegalovirus como causa de desarrollo de crioaglutininas y crioglobulinas en una paciente sometida a trasplante renal
E.J.. Fernándeza, Íngrid Auyanet Saavedraa, R.. Guerraa, M.A.. Péreza, E.. Boscha, A.. Ramíreza, S.. Suriaa, M.D.. Checaa
a Servicio de Nefrología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria España,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#44;&#160;</span>The development of cryoagglutinins and&#160;cryoglobulins following primary&#160;infection with cytomegalovirus &#40;CMV&#41;&#160;has been described in immunocompetent&#160;patients&#44; and manifests in the&#160;infection&#8217;s acute phase&#46; Few examples&#160;of literature refer to the effect that this&#160;primary infection may have on a&#160;patient subjected to a high-risk kidney&#160;transplant &#40;positive donor&#47;negative&#160;recipient&#41; following six months on prophylactic valgancyclovir&#44; which is&#160;universally accepted for this patient&#160;type&#46;&#160;We present the case of a 42-year old&#160;kidney transplant patient who&#160;developed mixed cryoagglutinins and&#160;cryoglobulins &#40;IgM&#47;IgG&#41; in the context&#160;of a primary CMV infection two&#160;months after ending prophylactic&#160;treatment with valgancyclovir&#46;&#160;He received a kidney transplant from a&#160;cadaver donor in July 2007&#46; The&#160;immunosuppressant regime consisted&#160;of basiliximab&#44; steroids&#44; tacrolimus&#160;and mycophenolate mofetil &#40;MMF&#41;&#46;&#160;During the first six months following&#160;the transplant&#44; prophylaxis was&#160;performed with oral valgancyclovir in&#160;doses of 900mg&#47;day&#46; Two months after&#160;finishing treatment&#44; he was seen for a&#160;mononucleosis-like syndrome and&#160;epigastric pain&#46; Tests showed&#160;leucopoenia &#40;3100 leukocytes&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44;&#160;hyperbilirrubinaemia &#40;1&#46;34mg&#47;dl&#41; and&#160;elevated LDH &#40;277U&#47;l&#41; with normal&#160;transaminases and normal kidney&#160;function&#46; CMV antigenaemia assay was&#160;performed&#44; which was positive with a titre&#160;of more than 100 infected cells per&#160;200&#44;000 leukocytes&#46; The patient was&#160;admitted for intravenous treatment with&#160;gancyclovir dosed at 5mg&#47;kg&#47;12 hours&#46;&#160;During admission&#44; the patient developed&#160;significant leucopoenia that required use&#160;of granulocyte-macrophage colonystimulating&#160;factor&#44; cryoagglutinins at a&#160;1&#47;64 titre and IgM&#47;IgG type cryoglobulins&#160;indicating type II cryoglobulinaemia&#44; as&#160;well as monoclonal IgM kappa precipitate&#160;visible in the proteinogram&#46; After&#160;evaluating the data with the help of the&#160;haematology department&#44; we considered&#160;them secondary to the viral infection&#46;&#160;MMF treatment was suspended&#44; and we&#160;decided to replace the tacrolimus with&#160;mTOR inhibitors because of their&#160;beneficial action in eradicating CMV&#160;infection&#46;<span class="elsevierStyleSup">1 </span>Treatment with gancyclovir&#160;was extended during 28 days&#44; at which&#160;point a gradual decrease was observed&#160;in the antigenaemia titres until they&#160;became completely negative&#46; Renal&#160;function continued to be stable at all&#160;times &#40;Cr 0&#46;9mg&#47;dl&#41;&#46; Cryoagglutinins and cryoglobulins became negative&#160;two months after admission of the&#160;patient&#59; the monoclonal spike was still&#160;present as late as seven months later&#46;&#160;The role that a primary infection with&#160;CMV or other viruses &#40;HBV&#44; VHC&#44;&#160;HIV&#41;<span class="elsevierStyleSup">2 </span>may play in the appearance of&#160;haematological and immunological&#160;abnormalities has been documented&#46;&#160;Development of type II&#160;cryoglobulinaemia is one of the most&#160;frequently-documented forms in the&#160;literature&#46;<span class="elsevierStyleSup">3&#44;4 </span>These abnormalities tend to&#160;be temporary and correlate with the&#160;progress of the infection&#46; This type of&#160;anomaly may also develop in kidney&#160;transplant patients&#46;<span class="elsevierStyleSup">5 </span>It tends to revert&#160;following total elimination of the virus&#160;through antiviral treatment&#44; and may&#160;complicate the treatment for these&#160;patients during the acute phase of the&#160;infection&#46;&#160;&#160;&#160;&#160;&#160;</p>"
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Article information
ISSN: 20132514
Original language: English
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