J Korean Soc Transplant.  2017 Jun;31(2):75-81. 10.4285/jkstn.2017.31.2.75.

A Case Treated with Extracorporeal Membrane Oxygenation for Disseminated Cytomegalovirus Infection after Liver Transplantation

• Park J
• Lee YH
• Choi YR
• Lee YJ
• Kim DJ
• Jheon S
• Cho YJ

• KMID: 2385532
• DOI: http://doi.org/10.4285/jkstn.2017.31.2.75

Abstract

Cytomegalovirus (CMV) is a clinically important pathogen in immunocompromised patients, especially after organ transplantation. However, there have been several reports of severe CMV infections in immunocompetent patients. This report presents a case of an immunocompetent patient who presented with fulminant hepatitis requiring liver transplantation. Because CMV was detected upon histopathologic review of the explanted liver, it was later assumed that CMV may be the primary cause of hepatitis. However, at the time of transplantation, we did not suspect CMV hepatitis. Following transplantation and initiation of immunosuppression, the patient developed viral sepsis with a disseminated CMV infection. Respiratory failure because of CMV pneumonia worsened despite antiviral therapy, and venovenous extracorporeal membrane oxygenation (ECMO) was initiated. Although ECMO has been traditionally contraindicated in patients with sepsis, this patient recovered and was successfully weaned off ECMO. CMV should be included in the differential diagnosis of fulminant hepatitis, even in immunocompetent patients, especially when liver transplantation is considered.

Keyword

Cytomegalovirus; Extracorporeal membrane oxygenation; Liver transplantation; Sepsis

MeSH Terms

Cytomegalovirus Infections*
Cytomegalovirus*
Diagnosis, Differential
Extracorporeal Membrane Oxygenation*
Hepatitis
Humans
Immunocompromised Host
Immunosuppression
Liver Transplantation*
Liver*
Organ Transplantation
Pneumonia
Respiratory Insufficiency
Sepsis
Transplants

Figure

• 

  Fig. 1. Bilateral lung opacities developed after liver transplantation. (A) As shown in the chest computed tomography image, bilateral consolidation was initially seen predominantly in both the upper lobes (postoperative day [POD] 5). (B) However, it progressed to involve the entire lung field (POD 7). (C) A simple chest radiograph taken after the initiation of extracorporeal membrane oxygenation (ECMO) showing that most of the lung was non-aerated (POD 10). (D) A chest radiograph taken 3 months after weaning off ECMO shows dramatic improvement (POD 120).

• 

  Fig. 2. (A) Histopathology of a liver biopsy specimen, which was obtained 7 days after transplantation, showing the microabscess with hepatocytic intranuclear cytomegaloviral inclusion (HE stain, ×400). (B) Immunohistochemical staining for cytomegalovirus is positive (×400).

• 

  Fig. 3. A timeline of clinically important diagnostic and therapeutic procedures. Abbreviations: POD, postoperative day; CMV, cytomegalovirus; WBC, white blood cell; ECMO, extracorporeal membrane oxygenation.

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