Cytomegalovirus Enteritis in a Kidney Transplant Recipient with Minimal Viremia

Introduction: Cytomegalovirus (CMV) is a frequent complication of transplant recipients, and therapy is warranted in cases of isolated viremia and organ infection. CMV Viral Load (VL) is sensitive for diagnosis and monitoring of treatment. The case discusses a patient with severe CMV enteritis that resulted in small bowel obstruction (SBO) with minimal VL. Case Description: 46M w/ESKD due to FSGS s/p DDKT (CMV – to +) 5 years ago, thymoglobulin induced. On tacrolimus, mycophenolate, belatacept. 2 years post-transplant, he had CMV viremia treated with valganciclovir. He presented 2 years later w/ abdominal pain + decreased appetite. CMV viremia confirmed with VL of 36.9IU/mL and was untreated due to the low VL. For the next two months, he was admitted and discharged 3x with conservative treatment of SBO. EGD noted impassible jejunal stricture w/ ulceration + for CMV immunohistochemical stain and EBER in situ negative. VL < 34.5. He was treated w/ IV Ganciclovir and transitioned to PO valganciclovir. He was readmitted with SBO, severe weight loss, and had a small bowel resection w/ anastomosis, mesenteric lymph node excision, and discharged once tolerating PO. Discussion: This patient had a low VL with biopsy proven CMV enteritis. American guidelines agree there is a lack of a widely applicable VL threshold for diagnosis and pre-emptive therapy. Antiviral therapy is recommended for asymptomatic viremia. A low VL does not rule out localized GI CMV disease.