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Recurrent cytomegalovirus disease, visceral leishmaniosis, and Legionella pneumonia after liver transplantation: a case report

[Infection récurrente à cytomégalovirus, leishmaniose viscérale et légionellose à la suite d’une transplantation hépatique : une étude de cas]

Nermin Halkic, MD^*, Riadh Ksontini, MD^*, Beatrix Scholl, MD^*, Catherine Blanc, MD, Tibor Kovacsovics, MD, Pascal Meylan, MD, Carmen Muheim, MD, Michel Gillet, MD^* and François Mosimann, MD^*

^* From the Departments of Surgery,
Anesthesiology,
the Division of Hematology,
and the Institute of Microbiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland.

Address correspondence to: Dr. Nermin Halkic, Service de Chirurgie, 1011 Lausanne-CHUV, Switzerland. Phone: 41-21-3142248; Fax: 41-21-3142360; E-mail: nhalkic{at}hospvd.ch

Purpose: Recurrent cytomegalovirus (CMV) disease is a frequent complication of liver transplantation. Visceral leishmaniosis in a transplant recipient is, on the other hand, extremely rare and only two cases of kala-azar have been described after liver transplantation. Immunosuppressed patients are known to be at risk of Legionella infection and the relationship between infection with this organism and hospital water supplies has been well described. These three diseases carry a high mortality rate. Our report examines the potential relationship between these complications.

Clinical features: We describe the case of a liver transplant recipient who presented the three complications successively and survived. After reviewing the literature, we explore hypotheses linking these infections and discuss treatment strategies.

Conclusions: In the patient described, infection with leishmania probably occurred months prior to the clinical presentation, a delay that matches the incubation period of kala-azar. The simultaneous onset of leishmaniosis and of a high CMV viremia may have been a coincidence. However, CMV infection has been shown to be an independent predictor of invasive fungal infection in liver transplant recipients. CMV does indeed have a suppressive effect on the humoral and cellular immune response in vitro as well as in vivo. The clinical manifestations of leishmaniosis may, therefore, have been precipitated in this patient by the additive immunosuppressive effect of antirejection drugs and CMV.

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