1 infec 13 - tabish60102

[ArchivalUser]

A 57-year-old man has a 3-day history of abdominal pain and bloating and increasing melena. Four months ago, he underwent heart transplantation because of severe ischemic cardiomyopathy. The patient has done well during the post-transplant period except for development of severe neutropenia that improved following adjusting his immunosuppressive regimen and discontinuing trimethoprim“sulfamethoxazole and ganciclovir.

On physical examination, temperature is 37.6 °C (99.7 °F), pulse rate is 98/min, respiration rate is 16/min, and blood pressure is 148/88 mm Hg. Cardiopulmonary examination is normal. The surgical scar on the anterior chest is well healed and shows no signs of inflammation. Abdominal distention, tympany, and marked epigastric tenderness are present, but no organomegaly or palpable masses are noted. The scar from the previous saphenous vein harvesting appears normal.

Laboratory Studies
Hemoglobin

7.1 g/dL (71 g/L)
Hematocrit

21%
Leukocyte count

15,400/μL (15.4 × 109/L)
Platelet count

454,000/μL (454 × 109/L)
Blood urea nitrogen

49 mg/dL (17.5 mmol/L)
Serum creatinine

2.1 mg/dL (185.68 µmol/L)
Serum electrolytes

Normal
Liver chemistry studies

Normal
Serum amylase

Normal
Serum lipase

Normal

Upper endoscopy shows several prepyloric ulcers, one of which is bleeding actively. A rapid urease test for Helicobacter pylori is negative. Biopsies of the ulcers are obtained; results are pending.

Which of the following pathogens is most likely causing this patient's current findings?

A Pneumocystis jiroveci (formerly Pneumocystis carinii)
] B Herpes simplex virus
C Epstein“Barr virus
D Cytomegalovirus
] E Polyomavirus BK

[ArchivalUser]

DD

[ArchivalUser]

DDD

[ArchivalUser]

(Correct Answer = D)
Key Point
Administration of ganciclovir or valganciclovir has greatly reduced, but not eliminated, the occurrence of cytomegalovirus infections in transplant recipients.

This patient most likely has cytomegalovirus infection involving the gastrointestinal tract. Administration of ganciclovir or valganciclovir has greatly reduced, but not eliminated, the occurrence of cytomegalovirus infections in transplant recipients. In addition, this patient's ganciclovir was discontinued after he developed neutropenia postoperatively. Gastrointestinal cytomegalovirus infection is a potentially fatal complication because an ulcer may perforate and cause peritonitis, or the patient may bleed to death because of sudden and massive hemorrhage.

He does not have respiratory findings consistent with development of Pneumocystis jiroveci (formerly Pneumocystis carinii) infection. Although herpes simplex virus does cause ulcerated lesions in the mouth and esophagus, it rarely, if ever, causes gastric or duodenal ulcers in transplant recipients. Epstein“Barr virus also does not cause gastrointestinal ulcers, and polyomavirus BK does not cause cutaneous or mucosal lesions.
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