TY - JOUR
T1 - Application of a New Paradigm for Cytomegalovirus Disease Prevention in Mayo Clinic's First Face Transplant
AU - Razonable, Raymund R.
AU - Amer, Hatem
AU - Mardini, Samir
N1 - Publisher Copyright:
© 2018 Mayo Foundation for Medical Education and Research
PY - 2019/1
Y1 - 2019/1
N2 - The optimal approach to preventing cytomegalovirus (CMV) disease after face transplant is unknown. We report an individualized hybrid approach, initially using valganciclovir prophylaxis followed by surveillance and preemptive therapy guided by viral and immunologic markers. A 31-year-old man received a near-total face allotransplant for gunshot injury–related severe facial deformities. He was CMV seronegative, and the donor was CMV seropositive (D+/R− mismatch), and he received intravenous ganciclovir followed by oral valganciclovir prophylaxis. Monthly CD8 + T-cell immune competence assay revealed no CMV-specific CD8 + T-cell immunity development during valganciclovir prophylaxis. Because of severe leukopenia, valganciclovir was discontinued at 7 months after transplant when the patient had recovered and sustained normal global CD8 + T-cell function. Weekly CMV polymerase chain reaction testing detected asymptomatic CMV replication (plasma CMV, 549 IU/mL) 3 months later. Short-course preemptive valganciclovir treatment resulted in sustained virologic clearance. The patient had development of CMV-specific CD8 + T cells (12 cells/μL) together with CMV IgM and IgG. No rejection or infection relapse was detected 20 months after transplant. In conclusion, viral and immunologic monitoring allowed for an individualized approach to effective CMV disease prevention after face transplant. This case highlights the importance of understanding the interplay between the host immunity and the pathogen in determining the clinical course and outcome of CMV and other infectious disease syndromes.
AB - The optimal approach to preventing cytomegalovirus (CMV) disease after face transplant is unknown. We report an individualized hybrid approach, initially using valganciclovir prophylaxis followed by surveillance and preemptive therapy guided by viral and immunologic markers. A 31-year-old man received a near-total face allotransplant for gunshot injury–related severe facial deformities. He was CMV seronegative, and the donor was CMV seropositive (D+/R− mismatch), and he received intravenous ganciclovir followed by oral valganciclovir prophylaxis. Monthly CD8 + T-cell immune competence assay revealed no CMV-specific CD8 + T-cell immunity development during valganciclovir prophylaxis. Because of severe leukopenia, valganciclovir was discontinued at 7 months after transplant when the patient had recovered and sustained normal global CD8 + T-cell function. Weekly CMV polymerase chain reaction testing detected asymptomatic CMV replication (plasma CMV, 549 IU/mL) 3 months later. Short-course preemptive valganciclovir treatment resulted in sustained virologic clearance. The patient had development of CMV-specific CD8 + T cells (12 cells/μL) together with CMV IgM and IgG. No rejection or infection relapse was detected 20 months after transplant. In conclusion, viral and immunologic monitoring allowed for an individualized approach to effective CMV disease prevention after face transplant. This case highlights the importance of understanding the interplay between the host immunity and the pathogen in determining the clinical course and outcome of CMV and other infectious disease syndromes.
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U2 - 10.1016/j.mayocp.2018.09.017
DO - 10.1016/j.mayocp.2018.09.017
M3 - Article
C2 - 30611443
AN - SCOPUS:85059360600
SN - 0025-6196
VL - 94
SP - 166
EP - 170
JO - Mayo Clinic proceedings
JF - Mayo Clinic proceedings
IS - 1
ER -