Cytomegalovirus antibody production in renal transplant patients

Clinical significance of cytomegalovirus infection in patients with inflammatory bowel disease

Cytomegalovirus (CMV) infection is common in humans. The virus then enters a “latency phase” and can reactivate to different stimuli such as immunosuppression. The clinical significance of CMV infection in inflammatory bowel disease is different in Crohn’s disease (CD) and ulcerative colitis (UC). CMV does not interfere in the clinical course of CD. However, CMV reactivation is frequent in severe or steroid-resistant UC. It is not known whether the virus exacerbates the disease or simply appears as a bystander of a severe disease. Different methods are used to diagnose CMV colitis. Diagnosis is classically based on histopathological identification of viral-infected cells or CMV antigens in biopsied tissues using haematoxylin-eosin or immunohistochemistry, other tests on blood or tissue samples are currently being investigated. Polymerase chain reaction performed in colonic mucosa has a high sensitivity and a positive result could be associated with a worse prognosis disease; further studies are needed to determine the most appropriate strategy with positive CMV-DNA in colonic mucosa. Specific endoscopic features have not been described in active UC and CMV infection. CMV colitis is usually treated with ganciclovir for several weeks, there are different opinions about whether or not to stop immunosuppressive therapy. Other antiviral drugs may be used. Multicenter controlled studies would needed to determine which subgroup of UC patients would benefit from early antiviral treatment.

Cytomegalovirus reactivation in critically ill immunocompetent hosts: a decade of progress and remaining challenges

Human cytomegalovirus (HCMV) is an undisputed pathogen in humans with severe immune compromise, which has historically been thought to carry little consequence in immunocompetent hosts. During the past decade, however, accumulating data suggest that significant numbers of immunocompetent humans reactivate HCMV during critical illness, and that these reactivation episodes are associated with worsened outcomes. Because most people are infected with this ubiquitous virus by adulthood, confirming pathogenicity has now become a clinical priority. In this article, we will review the incidence and implications of reactivation, the relevant immune responses and reactivation triggers relevant to the immunocompetent host. We will summarize the progress made during the past ten years, outline the work ongoing in this field, and identify the major gaps remaining in our emerging understanding of this phenomenon.

Cytomegalovirus in inflammatory bowel disease: pathogen or innocent bystander?

The role of cytomegalovirus (CMV) in exacerbations of inflammatory bowel disease (IBD) remains a topic of ongoing debate. Current data are conflicting as to whether CMV worsens inflammation in those with severe colitis, or is merely a surrogate marker for severe disease. The interpretation of existing results is limited by mostly small, retrospective studies, with varying definitions of disease severity and CMV disease. CMV colitis is rare in patients with Crohn's disease or mild-moderate ulcerative colitis. In patients with severe and/or steroid-refractory ulcerative colitis, local reactivation of CMV can be detected in actively inflamed colonic tissue in about 30% of cases. Where comparisons between CMV+ and CMV- steroid-refractory patients can be made, most, but not all, studies show no difference in outcomes according to CMV status. Treatment with antiviral therapy has allowed some patients with severe colitis to avoid colectomy despite poor response to conventional IBD therapies. This article reviews the immunobiology of CMV disease, the evidence for CMV's role in disease severity, and discusses the outcomes with antiviral therapy.

Intestinal infections in patients with acquired immunodeficiency syndrome. A prospective study in 132 patients

We studied prospectively 132 patients with acquired immunodeficiency syndrome to define the spectrum of enteric pathogens during this disease, with special reference to the correlation between the lesions, the infections, and the symptoms. Forty-four percent of the patients harbored at least one enteric pathogen: the most frequently recovered were Cryptosporidium (28), cytomegalovirus (16), Entamoeba histolytica (13), Giardia lamblia (9), and Mycobacterium avium intracellulare (7). Patients harboring pathogens were more likely to be diarrheics (69%) than patients without a pathogen (38%; P = 0.01) and more likely to have endoscopic lesions (29%) than patients without a pathogen (4%; P less than 0.001). The most common pathogen associated with diarrhea was Cryptosporidium. Cytomegalovirus, Entamoeba histolytica, and Salmonella typhimurium were each significantly associated with endoscopic lesions. Patients with cytomegalovirus infection tended to have a greater incidence of ulcer than patients without cytomegalovirus infection. Stool analysis diagnosed 61% of the infections, while endoscopy diagnosed 44%. Seven percent were recognized by stool analysis and endoscopy. When considering the 24 patients in whom accurate diagnosis warranted endoscopic biopsies, stool examination alone would have given an incomplete diagnosis in 14 patients (due to the presence of polyinfection). The frequency of inaccurate diagnosis of infection by stool determination alone, plus the development of new antiviral agents that suppress cytomegalovirus, may favor the earlier application of endoscopic evaluation in these patients.

Low and high molecular weight cytomegalovirus-specific immunoglobulin M antibody in renal transplant patients with cytomegalovirus infections

Sera from 27 renal transplant patients with primary and recurrent CMV infections and which were known to contain CMV-specific IgM antibodies were investigated by indirect immunofluorescence for the presence of virus-specific high molecular weight IgM (19S IgM) and low molecular weight IgM (7S IgM). After sucrose gradient fractionation of the sera, 19S IgM was found in all 27 patients, whereas 7S IgM was present in 11 out of 19 (56%) patients with primary CMV infection and in 1 out of 8 (12%) patients with recurrent CMV infection. The presence of 7S IgM was unrelated to the titre of the virus-specific IgM in whole serum. The presence of IgM rheumatoid factor was monitored by a sensitive fluorescence assay using measles virus antigen/antibody complexes. The absorption of the serum fractions with heat-aggregated gamma globulin failed to remove the specific IgM staining indicating that it was not due to IgM rheumatoid factor. On the other hand adsorption with protein A/sepharose removed the specific IgM staining from the 7S IgM fractions but not from the 19S IgM fractions. This suggests that specific 19S and 7S IgM antibodies may belong to different subclasses of IgM.

Cytomegalovirus-specific antibody responses in renal transplant patients with primary and recurrent CMV infections

Cytomegalovirus (CMV) specific immunoglobulin G (IgG) and immunoglobulin M (IgM) antibody responses were measured before and after renal transplantation in 20 patients with primary CMV infection and in 16 patients with recurrent CMV infection. In primary CMV infection IgG antibody titres to late antigen (IgG-LA) measured by indirect fluorescence (IFA) were approximately seven times higher than those obtained by the complement fixation test (CFT). In contrast, in recurrent CMV infection this difference was found to be about twofold. Virus-specific IgM antibody to late antigen (IgM-LA) was detected in 100 percent of patients with primary CMV infection and in only 50 percent of patients with recurrent CMV infection. The IgM-LA titres were highest in primary CMV infection and reached peak levels at approximately 10 weeks post transplantation, whereas in recurrent CMV infection the IgM-LA titres were lower and reached peak levels at three months post transplantation. Moreover, IgM-LA was found to persist in patients from both groups at nine months post transplantation. IgM antibody to early antigen (IgM-EA) was not detected in any patient in this study. However, significant fourfold titre rises in IgG antibody to EA (IgG-EA) were detected in 100 percent of patients with recurrent CMV infection and in 50 percent of patients with primary CMV infection. These results clearly show the difference in antibody responses to the various antigens of CMV in patients with primary and recurrent CMV infection.

[Detection of IgM antibodies in primary and secondary infections by cytomegalovirus in patients subjected to renal transplantation]

Foram acompanhados 27 pacientes submetidos a transplante renal para avaliação do comportamento dos anticorpos IgM e IgG CMV-específicos. Dos 27 casos estudados, 17 (63,0%) tinham anticorpos IgG, detectados pela reação de fixação de complemento (RFC), antes de serem submetidos ao transplante, e 10 (37,0%) eram soro negativos. A pesquisa de anticorpos IgM (técnica de imunofluorescência indireta) foi negativa em todas as amostras pré transplante. Num período de acompanhamento que variou de 28 a 425 dias (média de 115 dias) após o transplante, observou-se que 20 dos 27 (74,1%) apresentaram evidências sorológicas de infecçáo pelo CMV, ocorrendo a maioria dos casos (14/20, 70%) em pacientes que já tinham anticorpos para o CMV antes do transplante. A pesquisa de anticorpos IgM CMV-específicos foi positiva em 12 dos 14 pacientes com evidências sorológicas de reinfecção ou reativação da infecção pelo CMV, e em 100% (6/6) dos pacientes com infecção primária. Dentre os 10 pacientes acompanhados por mais de 4 meses, somente 1 (10%) negativou o IgM neste período.

Anomalous antibody responses in viral infection: specific stimulation or polyclonal activation?

Eighteen paired serum samples submitted for serodiagnosis of current infection showed anomalous antibody results by complement fixation test when tested with a battery of agents (viruses, Mycoplasma pneumoniae, and chlamydia) selected for testing on the basis of the symptoms of the patient. Seventeen serum pairs showed a fourfold or greater rise in titer of antibody to two agents in the battery, and one showed only a twofold rise in titer of antibody to the identified causative agent but an eightfold rise in titer of antibody to a heterologous agent. The 18 serum pairs were tested for IgM antibody to the two involved agents to determine whether IgM antibody tests would better distinguish the probable cause of the current infection. The serum pairs were separated into three groups based on their IgM responses. Group I consisted of six serum pairs with IgM antibody to both agents, four pairs of which showed a fourfold or greater rise in titer of IgM antibody to both agents, and two of which showed a rise in titer of IgM antibody to only one of the two agents. Group II consisted of 10 serum pairs with IgM antibody to one of the two agents, 7 pairs of which showed a fourfold or greater rise in titer of IgM antibody to the agent. Group III consisted of two serum pairs with no IgM antibody to either agent. Results show that determination of presence or absence of IgM antibody per se or demonstration of a fourfold or greater rise in specific IgM antibody titer does not always help in distinguishing the causative agent in current infections.

Congenital cytomegalovirus infection: on the relation between type and time of maternal infection and infant's symptoms

Maternal sera from 45 live-born infants with congenital cytomegalovirus (CMV) infection and 4 cases of legal abortion were analysed for CMV IgG and IgM. The investigation included cases from routine work and prospective studies of unselected infants. The purpose was to elucidate the relation between the maternal type and time of infection and the signs and symptoms of the offspring at birth and follow-up. Serological patterns compatible with primary maternal infection during trimesters I and II, but also with secondary infection (in at least 1 case), were associated with infant sequelae or death. Asymptomatic infant infection was found after primary infection in trimesters II and III and after secondary infection. Virus could not be isolated from some of the fetuses legally aborted due to primary maternal infection in trimester I. Attempts to demonstrate CMV IgM activity as a marker of active infection in sera from early pregnancy (period of legal abortion) were successful in only half of the 10 cases with infant sequelae or death. Symptoms at birth were prognostically serious, but the further course was sometimes uneventful even in infants with neonatal signs of cerebral infection. A few children without initial symptoms developed sequelae (impairment of hearing).

The detection of antibodies to cytomegalovirus in the sera of renal transplant patients by an IgM antibody capture assay

An IgM antibody capture assay for detection of cytomegalovirus (CMV) IgM antibody (MACRIA) was developed. It was shown to be of similar sensitivity to the indirect immunofluorescence test but has the advantage that rheumatoid factor does not react in it and pretest fractionation of serum is not required. It does, however, give false results with some Paul Bunnell-positive sera. The assay was used to measure the IgM response in 28 renal transplant patients followed prospectively. Seven patients (100%) with primary infections and six of 13 (46%) patients with secondary infections developed IgM by MACRIA. Nine of 13 (69%) patients with CMV IgM-positive sera had symptoms other than pyrexia associated with CMV infections, while only one of seven (14%) IgM-negative infections were symptomatic. Four of seven irreversible rejection episodes were associated with CMV IgM. The possible significance of CMV IgM production is discussed.

Histocompatibility types and antiviral antibodies in a diverse group of individuals

A study was made of the possible relationship between histocompatibility (HLA) antigens of the A and B loci and antibodies to cytomegalovirus, influenza A (victoria strain), measles, rotavirus, vaccinia, and varicella/zoster. A large and diverse group of unselected individuals was studied. A possible relationship was detected between the presence of the antigen B15 and a lack of circulating measles antibodies. The study group was divided into three sections: (a) healthy individuals, (b) "renal disease" patients awaiting renal transplantation, and (c) patients with various types of "other disease," mainly of an immunological nature. Significantly elevated titers to cytomegalovirus and varicella/zoster were found in the two diseased groups, but these elevated titers could not be linked with the presence or absence of any particular HLA A or B antigen.

Antibody to cytomegalovirus in patients with Sjögren's syndrome. As determined by an enzyme-linked immunosorbent assay

By use of enzyme-lined immunosorbent assay (ELISA), patients with Sjögren's syndrome were found to have levels of serum IgG antibody to cytomegalovirus twice those of matched control subjects, and IgM antibody levels which were three times as high. It may be relevant that features of cytomegalovirus infection are similar to those of Sjögren's syndrome.

Specific IgM class antibody production following infection with cytomegalovirus

Specific IgM class antibody production was studied in different groups of patients with characterized cytomegalovirus (CMV) infections using a radioimmunoassay (RIA). In pregnant women, IgM antibodies were detected only following primary infection and generally persisted less than 4 months. The demonstration of CMV-specific IgM during pregnancy is therefore diagnostic of recent primary CMV infection. In patients with symptomatic CMV infections, the appearance of IgM antibody was shown to be closely related to the onset of symptoms and coincided with production of complement fixing (CF) antibody. IgM antibodies were at maximum levels 3-4 weeks after presentation but generally declined to low or undetectable levels by 3-4 months. The significance of the results of testing for CMV-specific IgM in relation to clinical and other serological findings in these patients is discussed. IgM antibody production was also demonstrated in renal transplant patients with primary infections and in 6 of 21 recipients with secondary infections. In both groups the antibodies became detectable 3-6 weeks after transplantation but the titres were much higher following primary infection. IgM antibodies persisted throughout follow-up periods of up to 2 years after transplantation in some cases.

Le diagnostic rapide des infections à virus respiratoire syncytial (RS) par le titrage des IgM sériques (immunofluorescence indirecte)

En janvier 1981, au cours d'une épidémie d'infections respiratoires survenue chez des enfants âgés de 1 à 3 mois, 9 sujets atteints de bronchiolites sévères ont été hospitalisés dans un service de pédiatrie et 11 cas sont survenus dans le service.

Pour le diagnostic rapide direct, les prélèments pharyngés et/ou des aspirations nasales effectués chez 10/11 malades étaient tardifs par rapport à l'apparition des symptômes. Le diagnostic direct n'a été positif que dans 2 cas, et l'isolement d'un virus a toujours été négatif.

Pour le diagnostic sérologique, dans 9 cas/16, le premier sérum a été prélevé après 5 jours d'évolution. La réaction d'immunofluorescence (IF) a permis de faire le diagnostic d'une infection à virus respiratoire syncytial dans 13 cas. La r'eaction de fixation du complément (FC) est restée négative dans tous les cas.

Pendant la période de novembre 1980 à janvier 1981, on a prélevé les sérums de 32 enfants et 13 adultes hospitalisés pour des infections respiratoires aiguës (bronchites et bronchopneumophathies) et les sérums de 35 adultes hospitalisés dans un service de transplantation rénale. La réaction d'IF indirecte n'a pas été plus sensible que la FC, mais elle a permis:o1)

de différencier les infections primaires des réinfections;

2)

de prouver que dans la majorité de ces réinfections (13 cas/17), on pouvait détecter des IgM;

3)

de porter un diagnostic de certitude rapide sur un seul sérum dans environ 60% des cas, alors que la FC était négative (1 cas) ou ne permettait qu'un diagnostic présomptif (10 cas).

Direct enzyme-linked immunosorbent assay that uses peroxidase-labeled antigen for determination of immunoglobulin M antibody to cytomegalovirus

A direct enzyme-linked immunosorbent assay was developed for the measurement of immunoglobulin M (IgM) antibody to cytomegalovirus (CMV). Wells of microtiter plates were coated with anti-human IgM. Each patient's serum was added at a dilution of 1:100, and IgM from the serum was allowed to react with anti-human IgM. The amount of CMV-specific IgM antibody bound was determined by measuring the intensity of color change after the addition of peroxidase-labeled CMV antigen and substrate. Nuclei of infected cells served as an antigen source. CMV IgM could be detected only in IgM fractions of sera from patients with a recent CMV infection. Rheumatoid factor did not cause false-positive results. No cross-reactions were observed when paired sera from 22 patients with herpes simplex or varicella and single sera from 12 patients with suspected infectious mononucleosis were tested by the direct enzyme-linked immunosorbent assay. Each of 17 patients with a seroconversion for CMV antibody showed CMV-specific IgM antibody. In six of these patients the antibody was detected in the initial serum. The direct enzyme-linked immunosorbent assay for CMV IgM is a specific and sensitive test for the diagnosis of recent CMV infections and possesses distinct advantages over indirect tests.

Rapid detection of IgG and IgM antibodies for cytomegalovirus by the enzyme linked immunosorbent assay (ELISA)

A simple solid phase enzyme immunoassay for the detection of immunoglobulin G and M to cytomegalovirus (CMV) is described. Using this test IgM antibodies to CMV were detected in 0.7 per cent of newborns and regularly after CMV infection in transplant patients, furthermore in these latter patients IgM production was prolonged for several months. For the determination of IgG the enzyme immunoassay was more sensitive than the complement fixation test (CF) and the antibody titres were 4 to 8 fold higher. Since the ELISA test is rapid, specific and unexpensive it can become an acceptable routine diagnostic procedure.

A comparison of complement fixation, indirect immunofluorescence for viral late antigens, and anti-complement immunofluorescence tests for the detection of cytomegalovirus specific serum antibodies

It was shown that, on average, the titres of the sera obtained by both the anti-complement immunofluorescence (ACIF) and indirect immunofluorescence for viral late antigens (IFA-LA) procedures were approximately eight times higher than those obtained by complement fixation. There was no significant difference between the mean ACIF and IFA-LA titres, but the former method was preferred because it was not affected by non-specific staining. When 406 sera were screened for the presence or absence of antibodies, only five sera (1.2%) gave discordant results with the three tests. None of the tests could detect all of the sera that contained specific antibodies while each test detected over 98% of these sera. Thus, the increased sensitivity of the immunofluorescence procedures did not result in an appreciably increased rate of detection of cytomegalovirus seropositive sera.

Analysis of antibody assay methods and classes of viral antibodies in serodiagnosis of cytomegalovirus infection

Forty-nine serum pairs with antibody to cytomegalovirus (CMV) were evaluated for rises in antibody titer (greater than or equal to fourfold) by indirect hemagglutination (IHA) and complement fixation (CF), using a freeze-thaw antigen (FT) and a glycine extract antigen (GE). In this sample CF-FT detected more rises in antibody titer than did CF-GE. IHA detected the least number. The apparent reason for stationary antibody titers with CF-GE and IHA was the presence of high antibody titers in the first serum specimen. Separation of immunoglobulin classes of 20 serum pairs by sucrose gradient centrifugation indicated that these antibodies with IHA were of the immunoglobulin M (IgM) class and those with CF-GE were of the IgG class. By separation of immunoglobulin classes, rises in IgG CMV antibody titers were seen with IHA, rises not observed in the whole serum because of high IgM antibody titers in the first serum specimen. Absence of rises in antibody titers with CF-FT was due in part to too early sampling of the second serum specimen (less than 21 days) and in part to an apparent inability of some individuals to respond with antibody reactive with FT antigen. CF-GE and CF-FT antibodies of the IgM class were detected in some sera, usually in specimens collected more than 10 days after the onset of symptoms. Although reactive with CMV antigen, the specificity of these IgM antibodies in relation to rheumatoid factor requires clarification.

A longitudinal study of the serological and virological status of 18 women infected with cytomegalovirus

18 women, of known seropositivity, have been followed for between 18 and 66 months (mean 50.2 months) for viral excretion and serological changes. CMV was isolated from 58/146 (39.7 per cent) cultures from various sites, mostly cervix. A total of 129 sera were obtained and each was titrated in the late antigen, early antigen and anti-complement immunofluorescence assays, as well as the complement fixation and microneutralisation tests. From 3 women virus was consistently re-isolated, from 3 others virus was never re-isolated and the remaining 12 women excreted virus intermittently during the period of study. No significant changes in antibody titres could be detected by any of the 5 serological assays in any woman during periods of viral excretion. This suggests that local reactivation of latent CMV infection is not associated with a demonstrable systemic antibody response. Inter-assay correlations were sought for each of the 10 possible combinations of pairs of tests. Significant correlations were found for most pairs of tests, with the notable exception fo those involving the early antigen test. This confirms that antibodies detected in this assay are distinct from those detected by the other 4 serological assays.

Liver disease in renal transplant recipients

Liver disease is a common complication in renal transplant recipients. Several types of liver disease can occur. The most common are acute and chronic hepatitis. The variety of acute hepatitis include hepatitis A, hepatitis B, cytomegalovirus hepatitis, herpes simplex hepatitis and azathioprine hepatitis. The incidence of azathioprine hepatitis may not be as high as initially suggested. Chronic hepatitis is a serious problem because the disease seems to be progressive despite prednisone therapy. The causes of this chronic hepatitis are not fully known, although hepatitis B, cytomegalovirus and herpes simplex virus have been implicated. Discontinuation of azathioprine therapy has no appreciable effect on the course of chronic hepatitis.

Identification of pregnancies at risk from cytomegalovirus infection

The fluorescent antibody technique was used for the identification of specific cytomegalovirus IgM in the sera of twenty-four of 1065 unmarried pregnant women. Seventeen of them were followed to term and five infected infants were identified. Two other infants had CMV IgM in neonatal serum samples but virus excretion was not demonstrated. The congenital infection rate in this study was 5.3 per 1000 births by virus excretion and 7.9 per 1000 if cases with specific IgM are included; from previous studies a rate of 8.8 per 1000 was expected. The reasons for the lack of relationship between specific IgM in the mothers' serum and infected babies is discussed.

BK antibody and virus-specific IgM responses in renal transplant recipients, patients with malignant disease, and healthy people

Haemagglutination-inhibition (HAI) antibodies to BK virus, including BK-virus-specific IgM, were determined before and after renal transplantation in 20 patients, in 57 patients with malignant disease, and in 66 healthy controls, Before transplantation 11 of the renal transplant recipients were seronegative, but eight later serocconverted, two before and six after transplantation. Twenty of the patients with malignant disease and 22 controls were also seronegative. The geometric mean titre of BK HAI antibodies was significantly higher among transplanted patients (1/180) than among controls (1/90). BK-virus-specific IgM antibody was detected in seven renal transplant recipients, six patients with malignant disease, and 13 healthy controls. In transplant recipients BK-virus-specific IgM antibody usually persisted throughout the duration of the study, and studies on controls from whom second serum samples were available suggested that they too had persistent BK-virus-specific IgM responses. The geometric mean titre of BK-virus-specific IgM HAI antibody was significantly greater in post-transplantation sera (1/223) than in control sera (1/28). The specificity of the detection of BK-virus-specific IgM HAI antibody was confirmed by direct visualisation of antibody by immune electron microscopy. The persistence of BK-virus-specific IgM suggested that BK virus continued to provide an antigenic stimulus. Nevertheless, there was no obvious association between the serological findings and any clinical features, and prospective studies will be needed to elucidate any such association.

Reactivation of hepatitis b after transplantation operations

Surveillance of the staff and patients at the Cambridge Transplant and Dialysis Unit for hepatitis-B infection since 1968 has revealed the onset of antigenaemia in 6 patients in eight years. When the first serum of each patient admitted was examined for anti-HBc antibody, 23 of 380 (6-1%) patients were found positive. Since the presence of anti-HBc is taken to be evidence of previous infection, the occurence of antigenaemia in 3 of the positives when they were immunosuppressed after transplantation is believed to be due to reactivation of latent infection. This is a new factor to be considered in the control of hepatitis B after transplantation;

Comparative activity of immunofluorescent antibody and complement-fixing antibody in cytomegalovirus infection

Three different tests for detection of antibodies to human cytomegalovirus (CMV), complement fixing with antigen prepared by freeze-thaw disruption (CF-FT) or with antigen prepared by extraction with alkaline glycine buffer (CF-GE) and immunofluorescent staining (FA), were compared in renal transplant recipients and their healthy donors, FA and CF-GE tests yielded positive results at an identical and significantly higher frequency than CF-FT in both donors and recipients. CF-GE and FA performed on donors and recipients predicted all virus shedding post-transplant, whereas CF-FT did not. In the individuals who developed primary infection concurrent with the transplanted kidney, FA developed earlier than other antibodies in about one-half and at the same time in the remainder. In addition, the FA test could be completed more quickly and all sera could be interpreted, which made the FA test more useful than the CF-GE, but both of these tests were clearly superior to CF-FT.

Gastrointestinal hemorrhage secondary to cytomegalovirus after renal transplantation. A case report and review of the problem

Generalized cytomegalovirus infection was associated with massive and ultimately fatal upper gastrointestinal bleeding in a renal allograft recepient and persisted even after subtotal gastric resection. The surgical specimen and the remaining stomach at autopsy revealed multiple superficial ulcerations with cytomegalic inclusion bodies within the gastric mucosa. Renal failure in the terminal stages of the patient's illness required hemodialysis but did not seem to be the sole result of allograft rejection, suggesting that the renal dysfunction may be caused by the systemic viral infection.

Chronic antigenic stimulation, herpesvirus infection, and cancer in transplant recipients

An increased incidence of malignancy has been reported in transplant recipients. The pathogenesis of this increase was originally attributed to immunosuppressive therapy. However, not all tumours are increased in proportion to their occurrence in the general population-75% of reported tumours are lymphorproliferative or carcinoma of the skin, lip, or cervix. This cannot be explained by impaired immunosurveillance, and alternative hypotheses must be considered. 90% of transplant recipients develop clinical or serological evidence of herpesvirus infection. Herpesviruses have been implicated in the pathogenesis of lymphorproliferative tumours and carcinoma of the skin and cervix. They can remain in latent form and be reactivated by allogeneic stimulation and/or immunosuppression. These viruses localise to skin, cervix, and neural tissue-i.e., exactly those sites where cancer develops in transplant patients. Herpesvirus infections in association with the presence of an allogeneic graft in an immunosuppressed patient may be responsible for the increased incidence of both lymphoproliferative tumours and carcinoma of the skin, lip, and cervix in the transplant recipient.