PURPOSE: To report a case of retinal toxicity after an intravitreal ganciclovir injection to treat acute retinal necrosis in an eye filled with silicone oil.CASE SUMMARY: A 56-year-old male presented with ocular pain and visual loss in his right eye. His best-corrected visual acuity was 20/25, inflammatory cells in the anterior chamber, multiple retinitis lesions and retinal vessel occlusions in the peripheral retina and vitreous opacity were showed. Acute retinal necrosis was suspected, anterior chamber polymerase chain reaction (PCR) test was done. Aciclovir 2,400 mg/day intravenously and ganciclovir 2.0 mg were administered by intravitreal injection. After 4 days, retinitis was worsened and PCR test was positive for varicella zoster virus. Ganciclovir intravitreal injections were increased twice a week. After 16 days, retinal detachment occurred, so scleral encircling, vitrectomy, laser photocoagulation, and silicone oil tamponade were conducted. Ganciclovir 1.0 mg was injected at the end of surgery. The patient's visual acuity decreased to hand motion, and multiple crystal deposits with multiple retinal hemorrhages were observed in the right eye the next day. Visual acuity did not recover and optical coherent tomography showed that the macula was thinned.CONCLUSIONS: Visual loss seemed to be related with the retinal toxicity of ganciclovir. The increased local concentration due to the silicone oil tamponade is thought to have caused the toxicity.
Acyclovir ; Anterior Chamber ; Ganciclovir ; Hand ; Herpesvirus 3, Human ; Humans ; Intravitreal Injections ; Light Coagulation ; Male ; Middle Aged ; Polymerase Chain Reaction ; Retina ; Retinal Detachment ; Retinal Hemorrhage ; Retinal Necrosis Syndrome, Acute ; Retinal Vessels ; Retinaldehyde ; Retinitis ; Silicon ; Silicones ; Visual Acuity ; Vitrectomy

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions. Although viral reactivation is associated with DRESS syndrome, its role in TEN remains unclear. An 80-year-old woman visited our hospital because of fever and skin eruption. DRESS syndrome was diagnosed and was thought to caused by the use of the drug allopurinol. She was treated by discontinuation of the drug and administration of systemic steroids. She recovered from DRESS syndrome and was discharged from the hospital with tapering doses of steroids prescribed. One week after discharge, she visited our hospital again as the skin rash recurred and oral pain as well as oral and ocular mucosal lesions developed. In addition to the skin rash, blisters and Nikolsky's sign that were different from the skin lesions present in the previous DRESS syndrome were observed. Unlike those in DRESS syndrome, the viral serological test results were positive for anti-cytomegalovirus (CMV) IgM and CMV polymerase chain reaction. Therefore, it was thought that TEN was due to reactivation of CMV and she was treated this with ganciclovir and intravenous immunoglobulin. Here, we report a case of TEN caused by viral reactivation after DRESS syndrome developed after use of allopurinol which recovered after steroid treatment.
Aged, 80 and over ; Allopurinol ; Blister ; Cytomegalovirus Infections ; Cytomegalovirus ; Drug Hypersensitivity Syndrome ; Eosinophilia ; Exanthema ; Female ; Fever ; Ganciclovir ; Humans ; Immunoglobulin M ; Immunoglobulins ; Polymerase Chain Reaction ; Serologic Tests ; Skin ; Steroids ; Stevens-Johnson Syndrome

PURPOSE: We report a case of cytomegalovirus (CMV) retinitis following placement of an intravitreal dexamethasone implant in an immunocompetent patient diagnosed with non-infectious uveitis. CASE SUMMARY: A 60-year-old woman was referred to our hospital for recurrent anterior uveitis. Fundus examination and fluorescein angiography showed dense vitritis, but no definite retinal infiltration. After laboratory examinations, the patient was diagnosed with non-infectious panuveitis. Uveitis was much improved after the patient started taking oral steroid medication. However, the patient complained of systemic side effects from the oral steroids. Medication was stopped, and an intravitreal dexamethasone implant was fitted to address worsening inflammation. Two months later, perivascular retinal infiltration developed and vitritis recurred. Viral retinitis was suspected, and the patient underwent diagnostic vitrectomy adjunctive with intravitreal ganciclovir injection. Polymerase chain reaction of vitreous fluid confirmed the diagnosis of CMV retinitis. The patient has remained inflammation-free for more than 20 months after vitrectomy, single ganciclovir injection, and 2 months of oral valganciclovir medication. CONCLUSIONS: This is a case report of CMV retinitis following placement of an intravitreal dexamethasone implant in an immunocompetent patient without any risk factors or previous history of immunosuppression. Potential risk factors for CMV retinitis should be evaluated and careful follow-up should be performed when intravitreal dexamethasone injections are unavoidable for the treatment of non-infectious uveitis.
Cytomegalovirus Retinitis ; Cytomegalovirus ; Dexamethasone ; Diagnosis ; Female ; Fluorescein Angiography ; Follow-Up Studies ; Ganciclovir ; Humans ; Immunosuppression ; Inflammation ; Middle Aged ; Panuveitis ; Polymerase Chain Reaction ; Retinaldehyde ; Retinitis ; Risk Factors ; Steroids ; Uveitis ; Uveitis, Anterior ; Vitrectomy

Chest pain in kidney transplant patients is usually caused by cardiac or pulmonary problems. However, it may be rarely caused by opportunistic esophageal infections. A 66-year-old female kidney transplant recipient was admitted because of chest pain. She had been treated with high-dose steroid and immunosuppressants for acute T-cell-mediated rejection. Cardiologic and pulmonary evaluations had normal results. Endoscopic examination revealed three clear ulcerative lesions in the esophagus. Histological and immunohistochemical staining of the endoscopic biopsy specimens revealed coinfection of herpes simplex virus and cytomegalovirus. The patient was treated with intravenous ganciclovir for 2 weeks. Her symptoms completely resolved, and follow-up endoscopy revealed complete healing of the previous ulcers. Viral esophagitis should be considered in the differential diagnosis in kidney transplant recipients presenting with chest pain.
Aged ; Biopsy ; Chest Pain ; Coinfection ; Cytomegalovirus ; Diagnosis, Differential ; Endoscopy ; Esophagitis ; Esophagus ; Female ; Follow-Up Studies ; Ganciclovir ; Herpes Simplex ; Humans ; Immunosuppressive Agents ; Kidney ; Kidney Transplantation ; Simplexvirus ; Thorax ; Transplant Recipients ; Ulcer

Tacrolimus is widely used with other immunosuppressive agents to prevent rejection of a kidney transplant (KT). However, tacrolimus-induced fever is very rarely diagnosed. We report a case of tacrolimus-induced fever after KT. A 53-year-old female was diagnosed with cytomegalovirus (CMV) viremia. She had received a KT 2 months previously. Ganciclovir was started immediately at that time. A fever developed on day 12 of admission. Because of dysuria and a residual urine sensation with pyuria, we started intravenous antibiotics to treat urinary tract infection. Although other infectious reasons were ruled out and CMV viremia and the urinary tract infection improved, the fever spike did not improve. Thus, we suspected drug-induced fever. First, the ganciclovir and antibiotics were discontinued. However, the fever continued. To exclude tacrolimus-induced fever, tacrolimus was discontinued and cyclosporine was used with other immunosuppressive agents. Tacrolimus was discontinued after 1 day and the fever was no longer confirmed.
Anti-Bacterial Agents ; Cyclosporine ; Cytomegalovirus ; Dysuria ; Female ; Fever ; Ganciclovir ; Humans ; Immunosuppressive Agents ; Kidney Transplantation ; Kidney ; Middle Aged ; Pyuria ; Sensation ; Tacrolimus ; Urinary Tract Infections ; Viremia

A 14 year-old boy with acute lymphoblastic leukemia (ALL) on maintenance chemotherapy presented with vision-threatening cytomegalovirus (CMV) retinitis. Treatment with intavitreal ganciclovir injection (2 mg/0.1 mL) followed by oral ganciclovir resulted in successful resolution of CMV retinitis. Another 13 year-old boy with ALL on maintenance chemotherapy presented with prolonged fever with no response to antibiotics administration. CMV and real-time PCR revealed positive result and a titer of 2,618,700 copies/mL, respectively. Ganciclovir was used for more than the approved duration of treatment, but viral titer frequently recurred with elevated liver enzymes and fever. In these 2 cases of CMV infection, a high index of suspicion and prompt management is important in children receiving ALL chemotherapy.
Anti-Bacterial Agents ; Child ; Cytomegalovirus Infections ; Cytomegalovirus ; Drug Therapy ; Fever ; Ganciclovir ; Humans ; Liver ; Maintenance Chemotherapy ; Male ; Precursor Cell Lymphoblastic Leukemia-Lymphoma ; Real-Time Polymerase Chain Reaction ; Retinitis

Disseminated adenovirus infection can result in high mortality and morbidity in immunocompromised patients. Here, we report the case of a 10-year-old renal allograft recipient who presented with hematuria and dysuria. Adenovirus was isolated from his urine. His urinary symptoms decreased after intravenous hydration and reduction of immunosuppressants. However, 2 weeks later he presented with general weakness and laboratory tests indicated renal failure necessitating emergency hemodialysis. Adenovirus was detected in his sputum; therefore, intravenous ganciclovir and immunoglobulin therapy were initiated. Renal biopsy revealed diffuse necrotizing granulomatous tubulointerstitial nephritis compatible with renal involvement of the viral infection. Adenovirus was detected in his serum. Despite cidofovir administration for 2 weeks, adenovirus was also detected in the cerebrospinal fluid, resulting in generalized tonic-clonic seizure. The patient died 7 weeks after the onset of urinary symptoms. Adenovirus should be considered in screening tests for post-renal transplantation patients who present with hemorrhagic cystitis.
Adenoviridae Infections* ; Adenoviridae* ; Allografts* ; Biopsy ; Cerebrospinal Fluid ; Child* ; Cystitis ; Dysuria ; Emergencies ; Ganciclovir ; Hematuria ; Humans ; Immunization, Passive ; Immunocompromised Host ; Immunosuppressive Agents ; Kidney Transplantation ; Mass Screening ; Mortality ; Nephritis, Interstitial ; Opportunistic Infections ; Pediatrics ; Renal Dialysis ; Renal Insufficiency ; Seizures ; Sputum

Dasatinib, a tyrosine kinase inhibitor, is widely used for patients with chronic myeloid leukemia and Philadelphia chromosome-positive acute lymphoblastic leukemia. Although the drug has a potent immunosuppressive effect, infectious complications during dasatinib treatment have been reported rarely. We describe five patients who developed cytomegalovirus (CMV) colitis during dasatinib treatment, in whom the colitis was initially confused with other causes. The patients, three with chronic myeloid leukemia, and two with acute lymphoblastic leukemia, were diagnosed with CMV colitis based on endoscopic and histologic findings. The patients who examined blood CMV polymerase chain reaction were all positive. The patients received antiviral therapy in the form of either ganciclovir or valganciclovir, and the overall treatment outcome was fair. These cases suggest that physicians should consider the possibility of CMV reactivation when treating diarrhea and/or hematochezia in patients on dasatinib.
Colitis* ; Cytomegalovirus* ; Dasatinib* ; Diarrhea ; Ganciclovir ; Gastrointestinal Hemorrhage ; Hematologic Neoplasms* ; Humans ; Leukemia, Myelogenous, Chronic, BCR-ABL Positive ; Polymerase Chain Reaction ; Precursor Cell Lymphoblastic Leukemia-Lymphoma ; Protein-Tyrosine Kinases ; Treatment Outcome

Dasatinib, a tyrosine kinase inhibitor, is widely used for patients with chronic myeloid leukemia and Philadelphia chromosome-positive acute lymphoblastic leukemia. Although the drug has a potent immunosuppressive effect, infectious complications during dasatinib treatment have been reported rarely. We describe five patients who developed cytomegalovirus (CMV) colitis during dasatinib treatment, in whom the colitis was initially confused with other causes. The patients, three with chronic myeloid leukemia, and two with acute lymphoblastic leukemia, were diagnosed with CMV colitis based on endoscopic and histologic findings. The patients who examined blood CMV polymerase chain reaction were all positive. The patients received antiviral therapy in the form of either ganciclovir or valganciclovir, and the overall treatment outcome was fair. These cases suggest that physicians should consider the possibility of CMV reactivation when treating diarrhea and/or hematochezia in patients on dasatinib.
Colitis* ; Cytomegalovirus* ; Dasatinib* ; Diarrhea ; Ganciclovir ; Gastrointestinal Hemorrhage ; Hematologic Neoplasms* ; Humans ; Leukemia, Myelogenous, Chronic, BCR-ABL Positive ; Polymerase Chain Reaction ; Precursor Cell Lymphoblastic Leukemia-Lymphoma ; Protein-Tyrosine Kinases ; Treatment Outcome

The detailed kinetics of the cytomegalovirus (CMV)-specific T cell response in hematopoietic stem cell transplant (HCT) recipients have not yet been fully assessed. We evaluated these kinetics of CMV-specific T cell response and factors associated with high CMV-specific T cell responses 1 year after HCT. In HCT recipients, CMV pp65 and IE1-specific ELISPOT assay were performed before HCT (D0), and at 30 (D30), 90 (D90), 180 (D180), and 360 (D360) days after HCT. Of the 51 HCT recipients with donor-positive (D+)/recipient-positive (R+) serology, 26 (51%) developed CMV infections after HCT. The patterns of post-transplantation reconstitution for CMV-specific T cell response were classified into 4 types: 1) an initial decrease at D30 followed by gradual T cell reconstitution without CMV infection (35%), 2) an initial decrease at D30 followed by gradual T cell reconstitution preceded by CMV infection (35%), 3) failure of gradual or constant T cell reconstitution (26%), and 4) no significant T cell reconstitution (4%). There was no significant difference between ELISPOT counts of D360 and those of D0. High CMV-specific T cell responses at D360 were not associated with high CMV-specific T cell response at D0, CMV infection, ganciclovir therapy, graft versus host disease (GVHD), and immunosuppressant use. In conclusion, there are 4 distinct patterns of reconstitution of the CMV-specific T cell response after HCT. In addition, reconstituted donor-origin CMV-specific T cell responses appeared to be constant until day 360 after HCT, regardless of the level of the pre-transplant CMV-specific T cell response, CMV infection, and immunosuppressant use.
Cytomegalovirus ; Enzyme-Linked Immunospot Assay ; Follow-Up Studies* ; Ganciclovir ; Graft vs Host Disease ; Hematopoietic Stem Cell Transplantation* ; Hematopoietic Stem Cells* ; Kinetics* ; Theophylline