Cytomegalovirus infection in liver-transplanted children

Abstract

Cytomegalovirus (CMV) infection is a common complication of liver trans-plantation in children. The CMV serostatus of recipients and donors is the primary risk factor, and prophylaxis or pre-emptive strategies are recommended for high-risk patients. Graft rejection, coinfection and Epstein-Bar virus reactivation, which can lead to post-transplant lymphoproliferative disease, are indirect effects of CMV infection. Assessment of CMV infection viral load should be routinely performed upon clinical suspicion. However, tissue-invasive CMV disease is not associated with CMV viraemia and requires confirmation by tissue pathology. Oral valganciclovir and intravenous ganciclovir are equivalent treatments, and the duration of treatment depends on factors including CMV viral load, tissue pathology, and clinical response. Risk stratification by donor and recipient status prior to transplantation and post-transplantation antiviral prophylaxis or pre-emptive therapy are recommended. Adult guidelines have been established but additional study of the effectiveness of the preventive guidelines in children is needed. This review summarizes the burden, risk factors, clinical manifestations, laboratory evaluation, treatment, and prevention of CMV infection in children after liver transplantation.

Keywords: Children; Cytomegalovirus; Infection; Liver transplantation; Pediatric.

Figure 1

Cytomegalovirus tissue infection of the stomach and duodenum in a 13-mo-old boy and a 14-year-old boy with D⁺/R⁻ serostatus at transplant. Neither patient received antiviral prophylaxis. A and B: The 13-mo-old boy with D⁺/R⁻ serostatus at transplant presented with severe anaemia at 3 mo; C and D: The 14-year-old boy presented with haematemesis at 2 mo after liver transplantation.

Figure 2

Biopsies showing chronic active gastritis. A: Cytomegalovirus inclusion bodies are seen within mucous cells. The gastric biopsy is characterized by enlarged cells with basophilic nuclear and cytoplasmic inclusions; B: Liver biopsy shows a neutrophilic microabscess surrounding a hepatocyte with granular basophilic cytoplasmic cytomegalovirus inclusions; C: Positive cytomegalovirus immunohistochemistry in liver tissue.