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Angarone M, Snydman DR. Diagnosis and management of diarrhea in solid-organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13550. [PMID: 30913334 DOI: 10.1111/ctr.13550] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/30/2022]
Abstract
These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of diarrhea in the pre- and post-transplant period. Diarrhea in an organ transplant recipient may result in significant morbidity including dehydration, increased toxicity of medications, and rejection. Transplant recipients are affected by a wide range of etiologies of diarrhea with the most common causes being Clostridioides (formerly Clostridium) difficile infection, cytomegalovirus, and norovirus. Other bacterial, viral, and parasitic causes can result in diarrhea but are far less common. Further, noninfectious causes including medication toxicity, inflammatory bowel disease, post-transplant lymphoproliferative disease, and malignancy can also result in diarrhea in the transplant population. Management of diarrhea in this population is directed at the cause of the diarrhea, instituting therapy where appropriate and maintaining proper hydration. Identification of the cause to the diarrhea needs to be timely and focused.
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Affiliation(s)
- Michael Angarone
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David R Snydman
- Department of Medicine, The Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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Woodward J, Gkrania-Klotsas E, Kumararatne D. Chronic norovirus infection and common variable immunodeficiency. Clin Exp Immunol 2017; 188:363-370. [PMID: 27753065 PMCID: PMC5422859 DOI: 10.1111/cei.12884] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 12/21/2022] Open
Abstract
Chronic infection with norovirus is emerging as a significant risk for patients with immunodeficiency - either primary or secondary to therapeutic immunosuppression. Patients with primary immunodeficiency present a range of pathological responses to norovirus infection. Asymptomatic infections occur and differentiating viral carriage or prolonged viral shedding after self-limiting infection from infection causing protracted diarrhoea can be challenging, due to relatively mild pathological changes that may mimic other causes of diarrhoea in such patients (for instance pathogenic bacteria or parasites or graft-versus-host disease). However, a subset of patients with common variable immunodeficiency (CVID) experience a severe norovirus-associated enteropathy leading to intestinal villous atrophy and malabsorption. Symptomatic infection of up to 8 years has been demonstrated with clinical and histological recovery on viral clearance. Although oral immunoglobulins and nitazoxanide have been used to treat noroviral infections associated with immunosuppression, ribavirin is the only agent to date that has been linked to viral clearance in the Noroviral enteropathy associated with CVID.
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Affiliation(s)
- J Woodward
- Cambridge Intestinal Failure and Transplant (CIFT), Addenbrooke's Hospital, Cambridge University Foundation Hospitals NHS Trust, Cambridge, UK
| | - E Gkrania-Klotsas
- Department of Infectious Diseases, Addenbrooke's Hospital, Cambridge University Foundation Hospitals NHS Trust, Cambridge, UK
| | - D Kumararatne
- Department of Clinical Biochemistry and Immunology, Addenbrooke's Hospital, Cambridge University Foundation Hospitals NHS Trust, Cambridge, UK
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Avery RK, Lonze BE, Kraus ES, Marr KA, Montgomery RA. Severe chronic norovirus diarrheal disease in transplant recipients: Clinical features of an under-recognized syndrome. Transpl Infect Dis 2017; 19. [PMID: 28176463 DOI: 10.1111/tid.12674] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/27/2016] [Accepted: 11/06/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Norovirus (NV) infection has been reported as a cause of severe chronic diarrhea in transplant recipients, but this entity remains under-recognized in clinical practice, leading to diagnostic delays. Transplant clinicians should become familiar with this syndrome in order to facilitate early detection and management. METHODS Demographic, clinical, and outcomes variables were summarized from a series of transplant recipients with positive stool NV reverse transcription polymerase chain reaction (RT-PCR) assays at Johns Hopkins in 2013-2014. Factors associated with longer duration of symptoms were compared using random forest analysis. RESULTS Thirty-one of 193 (16%) transplant recipients who were tested for NV had positive stool RT-PCRs. Symptoms included diarrhea (100%), nausea/vomiting (58%), abdominal pain (52%), and wasting (35%). Acute kidney injury occurred in 23%, and persisted in 21% after 6 months. Median duration of diarrheal symptoms was 4 months (range, <1-20) and 11/31 (35.4%) patients had relapses after improvement. Wasting, incompatible kidney transplant status, and plasmapheresis were associated with longer diarrhea durations. Treatments included nitazoxanide (in 74%), reduction of immunosuppression (58%), and intravenous immunoglobulin (32%). Six patients died, but no deaths were attributed to NV. CONCLUSIONS It is important for clinicians to recognize that NV can cause severe chronic diarrhea in transplant recipients. In this series, receipt of a human leukocyte antigen- and/or blood type-incompatible kidney transplant, and plasmapheresis were associated with longer symptom duration.
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Affiliation(s)
- Robin K Avery
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Bonnie E Lonze
- Division of Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward S Kraus
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kieren A Marr
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Robert A Montgomery
- Division of Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
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Abstract
Noroviruses are among the most common cause of diarrhea in transplant recipients. The clinical spectrum of norovirus infection after transplant is increasingly being recognized. As substantial morbidity is now associated with norovirus infections in this population; the quest for rapid diagnostic modalities and newer therapies has expanded. Transplant recipients with norovirus infection are at risk for several complications, including protracted illness with malnutrition, organ failure, and chronic viral shedding. This review summarizes the current knowledge on the epidemiology, complications, diagnosis, and treatment of norovirus infection in the transplant setting.
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Affiliation(s)
- Michael P Angarone
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, 645 N Michigan Avenue, Suite 900, Chicago, IL, 60611, USA.
| | - Anna Sheahan
- Infection Control and Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mini Kamboj
- Infection Control and Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Abstract
PURPOSE OF REVIEW Diarrhea is a common complaint in the solid organ transplant recipient. Unlike the immune-competent patient, diarrhea in an organ transplant recipient may result in dehydration, increased toxicity of medications, and rejection. There is a wide range of causes for diarrhea in transplant recipients, but the most common causes are Clostridium difficile infection, cytomegalovirus, and norovirus. This review will focus on new epidemiology data as to the cause of diarrhea in the transplant population. RECENT FINDINGS Recent data have identified C. difficile, cytomegalovirus, and norovirus as important causes of diarrhea in this population, and management should be focused on these causes. Newer diagnostic platforms (such as PCR) are being evaluated, which may help in identification of the cause of diarrhea. SUMMARY New epidemiologic data and new testing techniques offer an opportunity for research into better testing strategies for transplant patients with diarrhea. These newer testing strategies may offer better insight into the cause of diarrhea and more appropriate treatment for this illness.
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Affiliation(s)
- Michael Angarone
- aDivision of Infectious Diseases bDivision of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Abstract
Norovirus, an RNA virus of the family Caliciviridae, is a human enteric pathogen that causes substantial morbidity across both health care and community settings. Several factors enhance the transmissibility of norovirus, including the small inoculum required to produce infection (<100 viral particles), prolonged viral shedding, and its ability to survive in the environment. In this review, we describe the basic virology and immunology of noroviruses, the clinical disease resulting from infection and its diagnosis and management, as well as host and pathogen factors that complicate vaccine development. Additionally, we discuss overall epidemiology, infection control strategies, and global reporting efforts aimed at controlling this worldwide cause of acute gastroenteritis. Prompt implementation of infection control measures remains the mainstay of norovirus outbreak management.
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Affiliation(s)
- Elizabeth Robilotti
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Stan Deresinski
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Benjamin A Pinsky
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
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Abstract
Diarrhea is a frequent but overlooked complication of kidney transplantation. Diarrhea is repeatedly neglected, often considered by patients and clinicians an unavoidable side effect of immunosuppressive regimens. It is, however, associated with a significant impairment in life quality. Severe and chronic posttransplant diarrhea may lead to dehydration, malabsorption, rehospitalization, immunosuppression, noncompliance, and a greater risk of graft loss and death. There is thus a need to optimize and standardize the management of posttransplant diarrhea with consistent diagnostic and therapeutic strategies. A recent study has suggested that the increased sensitivity of molecular tools might help in early pathogen identification and guidance of antimicrobial treatment. Most bacterial and protozoan infections are readily curable with appropriate antimicrobial agents; cryptosporidiosis and C. difficile infections may however be complicated by relapsing courses. In addition, identification of enteric viral genomes in stool has further reduced posttransplant diarrhea of unknown origin. Chronic norovirus-related posttransplant diarrhea, arising from the interplay of the virus and immunosuppressive drugs, has emerged as a new challenge in the field. Prospective and controlled studies are necessary to evaluate the efficacy and safety of innovative anti-norovirus therapeutics, as well as optimal immunosuppressive regimens, to enable viral clearance while preventing rejection and donor-specific antibody formation. This review seeks to provide a basis for the design of future clinical prospective studies.
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Abstract
Acute gastroenteritis caused by noroviruses often has a duration of 2-3 days and is characteristically self-limiting. In contrast, chronic infection caused by noroviruses in immunocompromised individuals can last from weeks to years, making clinical management difficult. The mechanisms by which noroviruses establish persistent infection, and the role of immunocompromised hosts as a reservoir for noroviruses in the general human population, are not known. However, study of this patient cohort may lead to new insights into norovirus biology and approaches to treatment.
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Affiliation(s)
- K Y Green
- Caliciviruses Section, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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Lee L, Ison M. Diarrhea caused by viruses in transplant recipients. Transpl Infect Dis 2014; 16:347-58. [DOI: 10.1111/tid.12212] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 12/11/2013] [Accepted: 12/21/2013] [Indexed: 01/25/2023]
Affiliation(s)
- L.Y. Lee
- Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
- Northwestern University Transplant Outcomes Research Collaborative; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| | - M.G. Ison
- Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
- Northwestern University Transplant Outcomes Research Collaborative; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
- Division of Infectious Diseases Northwestern University Feinberg School of Medicine; Chicago Illinois USA
- Division of Organ Transplantation; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
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Owen L, Jones G, Despott EJ, Murray C, Atkinson C, Beal I, Webster DP. Fatal enteritis in a renal transplant patient with post-transplant thrombotic microangiopathy undergoing plasma exchange therapy. J Clin Virol 2014; 59:213-7. [PMID: 24495848 DOI: 10.1016/j.jcv.2014.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 01/04/2014] [Accepted: 01/06/2014] [Indexed: 11/20/2022]
Affiliation(s)
- Leah Owen
- Watford General Hospital, Vicarage Road, Watford, Hertfordshire, WD18 0HB, United Kingdom.
| | - Gareth Jones
- Royal Free Hospital, Pond Street, London NW3 2QG, United Kingdom.
| | - Edward J Despott
- Royal Free Unit for Endoscopy & Centre for Gastroenterology, UCL Institute for Liver & Digestive Health, 8th Floor South Offices, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
| | - Claire Murray
- Department of Cellular Pathology, Royal Free Hospital NHS Trust, Pond Street, London, NW3 2QG, United Kingdom.
| | - Claire Atkinson
- Department of Virology, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
| | - Isobel Beal
- Royal Free Hospital, Pond Street, London NW3 2QG, United Kingdom.
| | - Daniel P Webster
- Department of Virology, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
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Abstract
Norovirus (NoV) are the most common cause of acute gastroenteritidis in humans worldwide. They are transmitted through consumption of contaminated food, or mostly by direct person-to-person contact. However, susceptibility to NoV infection is variable. NoVs recognize carbohydrate ligand, including A, B, H and Lewis histoblood group antigen (HBGAs) for attachment to human epithelial cells. Synthesis of these HBGAs requires various glycosyltransferase encoded by the ABO, FUT2, FUT3 genes. The presence of distinct carbohydrates structures dependent upon the combined polymorphism at the FUT2, FUT3 and ABO loci influences susceptibility to NoV infection. NoV-glycan interactions studies show that different strains recognize specific HBGAs. Together with herd immunity, HBGAs play a major role in the epidemiology and evolution of NoVs.
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Affiliation(s)
- N Ruvoën
- Unité de maladies réglementées - zoonoses, Oniris - École nationale vétérinaire, agroalimentaire et de l'alimentation Nantes Atlantique, site de la Chantrerie, 44307 Nantes, France.
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