Acute cytomegalovirus infection in liver transplant recipients: An independent risk for venous thromboembolism

Abstract

Acute cytomegalovirus (CMV) infection is a commonly encountered complication in the post liver transplant setting. We present a case of a 71-year-old male with acute CMV infection, initially presenting with a gastrointestinal bleed due to acute CMV gastritis and later on complicated by acute venous thromboembolism occurring as an unprovoked event in the post liver transplant period. Traditional risk factors for venous thromboembolism have been well described in the medical literature. Sporadic cases of thromboembolism due to CMV infection in the immune compromised patients have been described, especially in the post kidney transplant patients. Liver transplant recipients are equally prone to CMV infection particularly in the first year after successful transplantation. Venous thromboembolism in this special population is particularly challenging due to the fact that these patients may have persistent thrombocytopenia and anticoagulation may be a challenge for the treating physician. Since liver transplantation is severely and universally limited by the availability of donor organs, we feel that this case report will provide valuable knowledge in the day to day management of these patients, whose clinical needs are complex and require a multidisciplinary approach in their care and management. Evidence and pathophysiology linking both the conditions is presented along with a brief discussion on the management, common scenarios encountered and potential impact in this special group of patients.

Keywords: Cytomegalovirus; Venous thromboembolism; Orthotopic liver transplantation; Thrombocytopenia; Hypersplenism

Core tip: Liver transplant recipients are a special group of individuals whose clinical needs are complex due to the use of immunosuppressive agents. They are prone to several opportunistic infections which are not commonly encountered in regular clinical practice. Cytomegalovirus (CMV) infection is a well-recognized complication in the post-transplant setting which can affect the graft function and increase morbidity and mortality. Venous thromboembolism occurring in the setting of acute CMV infection in this group of patients is an important complication and we attempt to delineate the pathophysiology, discuss evidence linking both the conditions and provide practical points in the management of these complex individuals.