Intestinal Perforation Following Renal Transplantation: Report of 2 Cases Related to Cytomegalovirus Disease E. Abderrahim, L. Bouhamed, L. Raies, T.Ben Abdallah, H. Hedri, S. Barbouch, and H.Ben Maı¨z I T IS WELL ESTABLISHED that current immunosup- pressive protocols used in recipients of solid organ grafts have been associated with an increased risk of tissue-invasive cytomegalovirus (CMV) infection. 1,2 In these conditions, any segment of gastrointestinal tract may be involved with a high risk of serious complications, such as hemorrhage and perforation. 3 We report the observa- tions of 2 renal transplant recipients who developed 3 episodes of intestinal perforation related to CMV disease. CASE REPORTS Case 1 In October 1995, a 33-year-old man received a renal transplant from his mother. Both the donor and recipient were positive for CMV antibodies. The immunosuppression was maintained with cyclosporine (CsA), azathioprine, and prednisone. In August 2000, the recipient was readmitted with severe diarrhea and denutrition while receiving Mycophenolate Mofetil (MMF) and Prednisone; CsA had been stopped because of renal graft toxicity. The diagnosis of enteric CMV infection was made based on serologic and immunohistochemical findings. Intravenous Ganciclovir failed to provide prolonged remission of digestive symptoms, which relapsed 2 months later and were succeeded by an episode of acute peritonitis related to colic perforation necessitat- ing partial colectomy. In spite of the prolongation of Ganciclovir treatment, a second episode of acute peritonitis occurred a few weeks later that proved fatal due to grave sepsis and massive pulmonary embolism. Case 2 In October 1999, a 24-year-old woman received a cadaveric renal transplant for end-stage renal failure with undetermined cause. She was positive for CMV antibodies and her maintenance immuno- suppressive treatment included Prednisone, CsA, and Azathio- prine. Three months later, she developed fever, leucopenia, and diarrhea attributed to CMV infection treated successfully using Ganciclovir. In May 2001, she presented with rectal hemorrhage responsible for severe anemia. Colonoscopy showed two ulcerated lesions (Fig 1) without specific abnormalities on histological exam. CMV was detected using DNA in situ hybridation. Ganciclovir treatment resulted in good outcome and relief from abdominal pain and digestive hemorrhage, which relapsed 5 months later with features of systemic CMV infection. Ganciclovir was reintroduced but evolution was marked by the occurrence of an acute episode of peritonitis related to colic perforation necessitating partial colec- tomy. No relapse of digestive symptoms was noticed after 12 months of follow-up. DISCUSSION The involvement of the gastrointestinal tract by CMV is reported in 2% to 16% of recipients of solid organ grafts. It generates multiple digestive symptoms that depend on the affected site. CMV colitis represents a serious localization of CMV disease and can lead to grave complications such as hemorrhage and perforation. 3,4 Its diagnosis is often diffi- cult to establish due to nonspecific presenting symptoms and endoscopic features that are also observed in other pathological entities. Immunosuppressive drugs are also responsible for many digestive symptoms observed in trans- plant recipients and some authors reported serious compli- cations related to MMF, Azathioprine, and/or CsA. 2,5 The direct role of immunosuppression is excluded in our 2 patients based on the fact that digestive symptoms were not From the Department of Nephrology and Internal Medicine, Charles Nicolle Hospital, Tunis, Tunisia. This study was supported by the Tunisian State—Secretariat for Research and Technology (Health Laboratory 02). Address reprint requests to E. Abderrahim, Department of Nephrology and Internal Medicine, Charles Nicolle Hospital, Boulevard du 9, Avril 1006 BS, Tunis, Tunisia. E-mail: abderrahim.ezzeddine@rns.tn Fig 1. Case 2 colonoscopy showing ulcerated colitis. 0041-1345/03/$–see front matter © 2003 by Elsevier Inc. All rights reserved. doi:10.1016/j.transproceed.2003.08.063 360 Park Avenue South, New York, NY 10010-1710 2706 Transplantation Proceedings, 35, 2706 –2707 (2003)