Korean J Hematol.  2009 Dec;44(4):315-319. 10.5045/kjh.2009.44.4.315.

Ganciclovir and Leflunomide Combination Therapy for a Patient with Cytomegalovirus Pneumonia after Unrelated Allogenic Stem Cell Transplantation

• Lim JH
• Lee YN
• Ryu YS
• Kim HJ
• Kim KH
• Kim SH
• Kim HJ
• Lee SC
• Bae SB
• Kim CK
• Lee KT
• Park SK
• Won JH
• Hong DS
• Park HS
• Park JS
• Lee YK

• KMID: 2252119
• DOI: http://doi.org/10.5045/kjh.2009.44.4.315

Abstract

Cytomegalovirus (CMV) infection is an important cause of morbidity and mortality among transplant recipients. The first line standard therapy for CMV pneumonia is treatment with a combination of ganciclovir and immunoglobulin. Nevertheless, the mortality of CMV pneumonia is 30~70%. Leflunomide has been recently reported to have novel anti-CMV activity by inhibiting viron assembly. It is also cheaper and is more easily given orally as compared to ganciclovir. We report here on an allogenic stem cell transplant recipient who developed CMV pneumonia that was refractory to ganciclovir and immunoglobulin. The patient was successfully treated with a combination of leflunomide and ganciclovir.

Keyword

Cytomegalovirus; Ganciclovir; Leflunomide

MeSH Terms

Biological Agents
Cytomegalovirus
Ganciclovir
Humans
Immunoglobulins
Isoxazoles
Pneumonia
Stem Cell Transplantation
Stem Cells
Biological Agents
Ganciclovir
Immunoglobulins
Isoxazoles

Figure

• 

  Fig. 1. Blasts are counted over 90% of all nucleated cells (ANC). They have high N/C ratio, fine chromatin, deep basophilic cytoplasm and cytoplasmic vacuoles by using Wright-Giemsa stain (A: ×100, B: ×1,000).

• 

  Fig. 2. Chest radiograph shows peribronchial nodular increased opacites in both lower lung zones (A). Chest HRCT shows diffuse distribution of nodule and GGO in both mid and lower lung zones (B).

• 

  Fig. 3. Follow up chest HRCT after 2 weeks shows minimal decreased extent of diffuse distribution of GGO and consolidation in both lungs.

• 

  Fig. 4. Follow up chest HRCT after 2 months shows more decreased extent of diffuse distribution of GGO and consolidation in both lungs.

Reference

References

1. Lee WS, Jung CW, Lee KS, et al. Two cases of cytomegalovirus pneumonia after allogenic bone marrow transplantation. Korean J Med. 1996; 51:805–12.

2. Stocchi R, Ward KN, Fanin R, Baccarani M, Apperley JF. Management of human cytomegalovirus infection and disease after allogenic bone marrow transplantation. Haematologica. 1999; 84:71–9.

3. Waldman WJ, Knight DA, Lurain NS, et al. Novel mechanism of inhibition of cytomegalovirus by the experimental immunosuppressive agent leflunomide. Transplantation. 1999; 68:814–25.

4. Kim YJ, Kim SI, Kim YR, Yang CW, Kang MW, Bang BK. Two successfully treated cases of posttransplant pneumonia caused by CMV and aspergillus coinfection. J Korean Soc Transplant. 2008; 22:130–4.

5. Oh YC, Choi BR, Kim CA, Cho MJ. A study for detection of IgG, IgM antibody to cytomegalovirus in blood donors. Korean J Hematol. 1989; 24:75–9.

6. Meyers JD, Flournoy N, Thomas ED. Risk factors for cytomegalovirus infection after human marrow transplantation. J Infect Dis. 1986; 153:478–88.

7. The TH, van der Ploeg M, van der Berg AP, Vlieger AM, van der Giessen M, van Son WJ. Direct detection of cytomegalovirus in peripheral blood leukocytes–a review of the antigenemia assay and polymerase chain reaction. Transplantation. 1992; 54:193–8.

8. Goodrich JM, Bowden RA, Fisher L, Keller C, Schoch G, Meyers JD. Ganciclovir prophylaxis to prevent cytomegalovirus disease after allogeneic marrow transplant. Ann Intern Med. 1993; 118:173–8.

9. Chong AS, Huang W, Liu W, et al. In vivo activity of leflunomide: pharmacokinetic analyses and mechanism of immunosuppression. Transplantation. 1999; 68:100–9.

10. Sudarsanam TD, Sahni RD, John GT. Leflunomide: a possible altenative for ganciclovir sensitive and resistant cytomegalovirus infections. Postgrad Med J. 2006; 82:312–4.