Late cytomegalovirus infection after hematopoietic stem cell\ntransplantation: case reports
A 34 year-old male patient underwent related allogeneic HSCT eight months after the\ndiagnosis of B-cell acute lymphoblastic leukemia (ALL). The pre-transplant serostatus\nfor CMV indicated D+R+. Fludarabine, Ara-C, etoposide and\nmelphalan were used in the conditioning regimen. Prophylaxis for graft-versus-host\ndisease (GVHD) was carried out using cyclosporine and methotrexate initiated at D+4. The\npatient had some fever peaks on D+6 (38.5C), D+7 (38.4 and 38.7C) and D+12 (38.1C),\nhowever none were related to CMV. On D+21 the patient had no complaints and on D+24 he\nwas discharged. The patient received acyclovir (200 mg/day) as post-transplant\nprophylaxis for 47 days (D+28 to D+75). On D+56 he showed the first signs of chronic\nGVHD with elevated liver enzymes, labial mucosa with areas of hyperpigmentation and\nwhitish inner mouth mucosa, palmar and plantar hyperemia, nausea, itching of the back\nand oropharynx sensitivity. On D+63 the patient presented abdominal pain. Due to signs\nof skin, gastrointestinal (GIT), mouth, and liver GVHD, the cyclosporin was changed to\nalternating 100 mg and 200 mg doses and prednisone (60 mg/day) was associated. On D+94,\nthe patient reported asthenia, mild fever, epigastric pain, pain in the mouth and a sore\nthroat, all related to GVHD. A smear and CMV antigenemia during this period were both\nnegative. On D+101, the patient still had epigastric pain and pain in the oral cavity\nattributed to GVHD however the CMV antigenemia revealed 30 positive cells/200,000\nleukocytes (). Immediately, even with\nsubclinical infection, treatment was initiated with intravenous ganciclovir (5\nmg/kg/dose b.i.d) for ten days, continuing with ambulatory ganciclovir for 15 days. The\ntotal leukocyte counts at D+100 and D+101 were 2.73 x 109/L and 3.0 x 109/L,\nrespectively. The antigenemia became negative by D+118 and at D+148 remained negative.\nOn D+248, the patient still showed signs of liver, ocular, oral mucosa and skin GVHD.